Processing file: BT_Basavanthappa_Essentials_of_Medical_Surgical_Nursing_1.pdf

BT Basavanthappa

.

BT Basavanthappa<br>MSc (N) PhD<br>Professor and Principal (Retired)<br>Government College of Nursing, Bengaluru, Karnataka, India<br>PhD Guide for Research Work<br>Member<br>Faculty of Nursing, RGUHS, Karnataka, India<br>Academic Council, RGUHS, Karnataka, India<br>Examiner<br>UG and PG Courses on Nursing, Various Universities<br>Ex-Programme Incharge<br>IGNOU, BSc Nursing Course, Karnataka and Goa, India<br>Life Member<br>Nursing Research Society of India, New Delhi, India<br>Trained Nurses Association of India, New Delhi, India<br>President<br>RGUHS, Nursing Teachers Association, Karnataka, India<br>Winner<br>Bharat Excellence Award and Gold Medal<br>Vikas Ratan Gold Award<br>UWA Life Time Achievement Award<br>Shree Veeranjaneya "Shrujanashri" Award

Bengaluru - St Louis (USA) - Panama City (Panama) - London (UK) - New Delhi Ahmedabad ・ Chennai ・ Hyderabad ・ Kochi ・ Kolkata ・ Lucknow ・ Mumbai ・ Nagpur

Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd

4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357, Fax: +91-11-43574314

B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021 +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: jaypee@jaypeebrothers.com, Website: www.jaypeebrothers.com

• Ahmedabad, Phone: Rel: +91-79-32988717, e-mail: ahmedabad@jaypeebrothers.com
• Bengaluru, Phone: Rel: +91-80-32714073, e-mail: bangalore@jaypeebrothers.com
• Chennai, Phone: Rel: +91-44-32972089, e-mail: chennai@jaypeebrothers.com
• Hyderabad, Phone: Rel:+91-40-32940929, e-mail: hyderabad@jaypeebrothers.com
• Kochi, Phone: +91-484-2395740, e-mail: kochi@jaypeebrothers.com
• Kolkata, Phone: +91-33-22276415, e-mail: kolkata@jaypeebrothers.com
• Lucknow, Phone: +91-522-3040554, e-mail: lucknow@jaypeebrothers.com
• Mumbai, Phone: Rel: +91-22-32926896, e-mail: mumbai@jaypeebrothers.com
• Nagpur, Phone: Rel: +91-712-3245220, e-mail: nagpur@jaypeebrothers.com

• North America Office, USA, Ph: 001-636-6279734, e-mail: jaypee@jaypeebrothers.com, anjulav@jaypeebrothers.com
• Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: cservice@jphmedical.com Website: www.jphmedical.com
• Europe Office, UK, Ph: +44 (0) 2031708910, e-mail: info@jpmedpub.com

© 2011, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2011 ISBN: 978-93-5025-136-2 Typeset at JPBMP typesetting unit Printed at

.

It gives me immense pleasure and satisfaction to introduce "Essentials of Medical Surgical Nursing" to nursing community. In offering this text, I remain grateful for the support given to my all titles on Nursing and who have provided constructive feedback as well as encouraging commands.

This book is intended to provide an easily comprehensible, non-intimidating and concise text on the subject matter of Medical Surgical Nursing to the nursing students. There was a felt need among nursing students and teachers to have a handy book on "Medical Surgical Nursing" which caters to the needs of Indian situation. It has been written in accordance with the needs of the present existing syllabus prescribed for the nursing course at degree level. The information provided is based on established knowledge and practice and also backed by scientific principles. Every attempt has been made to maintain simplicity and lucidity of language and style.

I hope, this book will continue to serve as good source not only for nursing students but also a source reference and revision to the nurses who are in service and educational settings.

I am aware of manifold reasons, errors might have crept in. I shall feel obliged, if such errors are brought to my notice. I sincerely, welcome constructive criticism from readers that would help me to enrich my knowledge.

BT Basavanthappa

.

I owe a great deal of thanks to many who encouraged and supported me with their time and encouragement throughout.

• Shri G Basavannappa, Former Minister of Karnataka State for having initiated and support me to take up this "Noble Nursing Profession" as my career.
• Dr (Mrs) Manjula K Vasundhra, Former Professor and HOD of Community Medicine, Bangalore Medical College, who continuously encouraged me to write texts in the field of Nursing since nursing is a major force in Medical and Health services.
• My father Shri Thukkappa, who continuous to grace for the progress of my career and all-around development of my personality for the welfare of the community.
• My mother Smt Hanumanthamma who continues to be a bright spot in the lives of all who knew her and whose grace gave me strength to progress of my life.
• My wife Smt Lalitha, who gives meaning to my life in so many ways. She is the one whose encouragement keep me motivated, whose support gives me strength and whose gentleness gives me comfort.
• My lovely children BB Mahesh and BB Gaanashree, for all the joy they provided me and all the hope that they instill me and who bare with patient throughout my works of the nursing texts. They keep me young at heart.
• Finally my warmest appreciation goes to M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, for sharing my vision for this book and giving me the chance to turn vision into reality.

.

1. Introduction to Medical Surgical Nursing ..... 1

• Evolution medicine and nursing in India ..... 1
• Traditional medium and surgery in India ..... 1
• Golden period of Indian medicine ..... 1
• Hindu writings on diagnosis and prognosis ..... 2
• Hindu surgery ..... 2
• Chronological events ..... 3
• Nursing in India ..... 5
• Auxiliary nursing ..... 7
• Registration of nurses ..... 8
• Nurses responsibility for the future of nursing ..... 8
• Concepts of health and illness ..... 10
• Illness, sickness, and disease ..... 12
• Illness behavior stages ..... 13
• Sick role behavior ..... 15
• Effects of hospitalization ..... 16
• Effects of illness on family member ..... 17
• Infection and inflammation ..... 19
• Asepsis ..... 20
• Role of nurses in surgical setting ..... 22
• General preoperative care ..... 22
• General postoperative care ..... 24
• Intensive care unit ..... 25
• Wound and its healing ..... 26

2. Management of Common Signs and Symptoms ..... 31

• Management of fluid and electrolytic balance ..... 31
• Management of vomiting (see chapter 4)
• Management of dyspnea and cough (see chapter 3)
• Management of fever ..... 34
• Management of shock (see chapter 5)
• Management of unconscious patient ..... 35
• Management of pain ..... 44
• Management of incontinence (see chapter 7)

3. Nursing Management of Respiratory Problems ..... 53

• Introduction ..... 53

• Nursing assessment of respiratory system ..... 53

• Diagnostic studies of respiration system ..... 56

• Acute bronchitis ..... 59

• Pneumonia ..... 60

• Tuberculosis ..... 63

• Bronchiectasis ..... 66

• Empyema ..... 67

• Lung abscess ..... 67

• Occupational lung diseases ..... 68

• Lung cancer ..... 70

• Nursing management of thoracic surgery ..... 72

• Chest trauma and thoracic injuries ..... 73

• Rib fractures ..... 75

• Flail chest ..... 75

• Pneumothorax ..... 76

• Hemothorax ..... 77

• Pleural effusion ..... 77

• Pulmonary embolism ..... 79

• Pulmonary hypertension ..... 82

• Cor pulmonale ..... 85

• Lung transplantation ..... 85

• Pulmonary contusion ..... 87

• Chronic bronchitis ..... 87

• Emphysema ..... 89

• Asthma ..... 91

• Cystic fibrosis ..... 94

• Respiratory failure ..... 95

• Chronic obstructive pulmonary disease (COPD) ..... 96

4. Nursing Management of Digestive Disorders ..... 114

• Introduction ..... 114

• Nursing assessment of digestive system ..... 114

• Diagnosis studies in digestive system ..... 118

• Radiological studies ..... 119

• Endoscopic examination ..... 122

• Liver biopsy ..... 123

• Problems of mouth ..... 123

• Oral infections and inflammation ..... 123

• Oral cancer ..... 125

• Nausea and vomiting ..... 128

• Gastroesophageal reflux disease (GERD) ..... 131

• Hiatal hernia ..... 134

• Achlasia ..... 135

• Esophageal carcinoma ..... 137

• Gastritis and dyspepsia ..... 139

• Acute gastritis ..... 139

• Chronic gastritis ..... 140

• Upper gastrointestinal bleeding ..... 141

• Peptic ulcer disease ..... 141

• Cancer of the stomach ..... 146

• Irritable bowel syndrome ..... 148

• Diarrhea ..... 148

• Fecal incontinence ..... 151

• Constipation ..... 152

• Acute abdomen ..... 153

• Abdominal trauma ..... 154

• Appendicitis ..... 155

• Peritonitis ..... 156

• Diverticulitis ..... 157

• Inflammatory bowel disease ..... 158

• Ulcerative colitis ..... 158

• Crohn's disease ..... 160

• Intestinal obstruction ..... 161

• Colorectal cancer ..... 163

• Ostomy surgery ..... 164

• Anorectal disorder ..... 166

• Jaundice ..... 168

• Hepatitis ..... 168

• Cirrhosis of liver ..... 172

• Cholelithiasis ..... 174

• Primary sclerosing cholangitis ..... 176

• Chronic pancreatitis ..... 179

5. Nursing Management of Cardiovascular Disorders ..... 180

• Nursing assessment of cardiovascular system ..... 180

• Physical examination ..... 181

• Diagnosis studies of CVS ..... 184

• Hypertension ..... 189

• Coronary artery disease ..... 195

• Angina pectoris ..... 196

• Myocardial infarction ..... 199

• Shock ..... 205

• Cardiogenic shock ..... 213

• Heart failure ..... 214

• Cardiac dysrhythmias ..... 219

• Inflammatory heart disease ..... 229

• Pericarditis ..... 229

• Myocarditis ..... 231

• Infective endocarditis ..... 232

• Rheumatic heart disease ..... 234

• Valvular heart disease ..... 235

• Mitral stenosis ..... 235

• Mitral regurgitation ..... 236

• Mitral valve prolapse ..... 237

• Aortic stenosis ..... 237

• Aortic regurgitation ..... 238

• Tricuspid valve disease ..... 238

• Pulmonary valve disease ..... 239

• Cardiac surgery ..... 239

• Arterial disorders ..... 242

• Acute arterial occlusive disorder ..... 244

• Chronic arterial occlusive disease ..... 246

• Buerger's disease ..... 248

• Raynaud's disease ..... 248

• Amputation and its management ..... 249

• Disorders of veins ..... 250

• Deep vein thrombosis ..... 250

• Venous stasis ulcer ..... 253

• Pulmonary embolism ..... 253

6. Nursing Management of Hematological Disorders ..... 255

• Introduction ..... 255

• Nursing assessment of the hemotological system ..... 255

• Diagnosis studies of the hemotological system ..... 257

• Hematological disorders ..... 260

• Disorders of erythrocytes ..... 260

• Anemias ..... 260

• Iron deficiency anemia ..... 262

• Megaloblastic anemia ..... 263

• Thalassemia ..... 264

• Aplastic anemia ..... 265

• Hemolytic anemia ..... 267

• Hereditary spherocytosis ..... 268

• Enzyme deficiency anemia ..... 268

• Sickle cell disease ..... 269

• Polycythemia vera/erythrocytosis ..... 271

• Anemia caused by blood loss ..... 272

• Disorders and hemostasis ..... 273

• Thromobocytopenia ..... 273

• Thrombocytosis ..... 276

• Disorder of coagulation ..... 276

• Hemophilia ..... 276

• Vitamin K deficiency ..... 278

• Disseminated intravascular coagulation (DIC) ..... 278

• Disorders of WBCs ..... 280

• Neutropenia ..... 280

• Neutrophilia ..... 281

• Leukemia ..... 282

• Acute lymphocytic leukemia ..... 282

• Acute myelogenous leukemia ..... 283

• Chronic lymphocytic leukemia ..... 283

• Chronic myelogenous leukemia ..... 284

• Lymphedema ..... 284

• Lymphoma ..... 285

• Hodgkins disease ..... 285

• Non-Hodgkins lymphoma ..... 286

• Infectious mononucleosis ..... 288

• Multiple myeloma ..... 288

• Immune thrombocytopenia ..... 289

• Blood transfusion ..... 289

7. Nursing Management of Genitourinary Disorders ..... 295

• Introduction ..... 295
• Nursing assessment of genitourinary system ..... 295
• Diagnostic studies of genitourinary system ..... 296
• Urine studies ..... 296
• Inflammatory disorders of urinary system ..... 300
• Urinary tract infections ..... 300
• Cystitis ..... 303
• Glomerulonephritis ..... 304
• Acute glomerulonephritis ..... 304
• Chronic glomerulonephritis ..... 305
• Nephrotic syndrome ..... 306
• Good Pastures syndrome ..... 307
• Renal artery stenosis ..... 308
• Renal vein thrombosis ..... 309
• Nephrosclerosis ..... 309
• Obstructive uropathies ..... 310
• Hydronephrosis ..... 310
• Renal calculi ..... 311
• Renal tumor ..... 315
• Wilm's tumor ..... 315
• Urinary incontinence ..... 318
• Reno-ureteral surgery ..... 322
• Urinary diversion ..... 322
• Acute renal failure ..... 324
• Chronic renal failure ..... 328
• Dialysis therapy ..... 332

8. Nursing Management of Disorders of Reproductive System ..... 333

• Introduction ..... 333

• Nursing assessment of male and female reproductive system ..... 333

• Diagnostic studies of reproduction system ..... 337

• Reproductive problem of females/women ..... 340

• Vaginitis ..... 340

• Cervicitis ..... 342

• Bartholinitis ..... 343

• Pelvic inflammatory disease ..... 343

• Problems of menstruation ..... 344

• Premenstrual syndrome ..... 345

• Dysmenorrhea ..... 346

• Amenorrhea ..... 347

• Dysfunctional uterine bleeding (DUB) ..... 348

• Endometriosis ..... 350

• Uterine prolapse ..... 351

• Fistulas ..... 353

• Neoplasm of the female reproductive system ..... 355

• Cervical polyps ..... 355

• Cervical cancer ..... 355

• Uterine leiomyoma (fibroids) ..... 358

• Endometrial cancer ..... 359

• Ovarian cyst ..... 360

• Ovarian cancer ..... 361

• Vulvar cancer ..... 362

• Surgeries of female reproductive system ..... 363 Infertility ..... 364

• Problems of the breast ..... 366

• Benign breast problems ..... 366

• Fibroadenoma of breast ..... 368

• Breast infections ..... 368

• Breast cancer ..... 370

• Nursing management of mastectomy ..... 373 Male breast problems ..... 374

• Gynecomastia ..... 374

• Male breast cancer ..... 375 Male reproductive problem ..... 375

• Epididymitis ..... 376

• Orchitis ..... 377

• Testicular torsion ..... 379

• Testicular cancer ..... 379

• Problems of prostate ..... 381

• Prostatitis ..... 381

• Benign prostatic hyperplasia (BPH) ..... 382

• Cancer of the prostate ..... 384

• Problems of the penis ..... 386

• Congenital problems of penis ..... 386

• Phimosis and paraphimosis ..... 386

• Cancer of the penis ..... 387

• Erectile dysfunction/impotence ..... 388

• Priapism ..... 389 Sexually transmitted diseases ..... 390

• Gonorrhea ..... 390

• Syphilis ..... 391

• Herpes genitalis ..... 392

• Chlamydial infections ..... 393

• Lymphogranuloma venereum ..... 393

• Chancroid ..... 394

• Granuloma inguinale ..... 394

• Condylomata acuminata ..... 395

• Trichomaniasis ..... 396

• Hepatitis B virus ..... 396

• HIV infection and AIDS ..... 398

9. Nursing Management or Endocrine Disorders ..... 405

• Introduction ..... 405
• Nursing assessment of the endocrine system ..... 405
• Diagnostic studies of the endocrine system ..... 406
• Disorders of pituitary glands ..... 407
• Hyperpituitarism ..... 407
• Prolactin hypersecretion ..... 409
• Growth hormone hypersecretion ..... 410
• Hypopituitarism ..... 411
• Hyperfunction of posterior pituitary ..... 413
• SIADH ..... 413
• Diabetes insipidus ..... 415
• Disorders of thyroid gland ..... 416
• Hyperthyroidism ..... 416
• Hypothyroidism ..... 420
• Cancer of thyroid gland ..... 423
• Disorders of parathyroid gland ..... 425
• Hyperparathyroidism ..... 425
• Hypoparathyroidism ..... 427
• Disorders of adrenal gland ..... 429
• Cushing syndrome ..... 429
• Iatrogenic Cushing's syndrome ..... 431
• Aldosteronism ..... 433
• Adrenocortical insufficiency ..... 433
• Addisons disease ..... 433
• Disorders of pancreas ..... 435
• Diabetes mellitus ..... 435
• Complication of DM ..... 440
• Hyperglycemic hyperosmolar non ketotic coma ..... 441
• Chronic complication of DM ..... 441
• Hypogylcemia in DM ..... 442
• Hypoglycemia in non DM ..... 443
• The Diabetic foot ..... 444

10. Nursing Management of Integumentary Disorder and Burns ..... 446

• Introduction ..... 446

• Nursing assessment of integumentary system ..... 446

• Diagnostic studies of integumentary system ..... 450

• Pediculosis common skin problems ..... 451

• Scabies ..... 452

• Fungal infections ..... 453

• Candidiasis ..... 453

• Dermatophytosis ..... 454

• Tenia capitis ..... 454

• Tenia corporis ..... 454

• Tenia cruris ..... 454

• Tenia pedis ..... 455

• Tenia unguium ..... 455

• Bacterial infections ..... 455

• Impetigo ..... 455

• Folliculitis ..... 456

• Furuncle and carbuncles ..... 456

• Erysipelas ..... 457

• Herpes simplex ..... 457

• Herpes zoster ..... 457

• Verruca vulgaris ..... 458

• Warts ..... 459

• Allergic conditions of the skin ..... 459

• Contact dermatitis ..... 459

• Urticaria ..... 460

• Drug reaction ..... 460

• Atopic dermatitis ..... 460

• Other types ..... 461

• Skin reactions ..... 462

• Lupus erythematosus ..... 463

• Papulosquamous diseases ..... 464

• Psoriasis ..... 464

• Pityriasis rosea ..... 465

• Acne ..... 465

• Bullous disease ..... 466

• Pemphigus vulgaris ..... 466

• Tumors of the skin ..... 467

• Benign tumors ..... 467

• Premalignant lesion ..... 468

• Malignant lesion ..... 469

• Nursing management of dermatological surgery ..... 470

• Pressure ulcers ..... 471

• Burns ..... 473

• Classification of severity of burns ..... 476

11. Nursing Management of Musculoskeletal Disorders ..... 483

• Introduction ..... 483

• Nursing assessment of musculoskeletal system ..... 483

• Diagnosis studies of the musculoskeletal system ..... 487

• Sprains and strains ..... 491

• Dislocation and subluxation ..... 492

• Carpal tunnel syndrome ..... 493

• Repetitive strain injury ..... 493

• Rotator cuff injury ..... 494

• Meniscus injury ..... 494

• Bursitis ..... 494

• Muscle spasms ..... 495

• Fractures ..... 495

• Fracture reduction ..... 498

• Traction ..... 499

• Fracture immobilization ..... 501

• Internal fixation ..... 503

• Management of complications of fracture ..... 503

• Inflammatory and degenerative disorder-musculoskeletal system ..... 506

• Rheumatoid arthritis ..... 506

• Osteoarthritis ..... 511

• Juvenile rheumatoid arthritis ..... 515

• Gouty arthritis ..... 516

• Septic arthritis ..... 517

• Lymes disease ..... 518

• Seronegative arthropathies ..... 520

• Psoriatic arthritis ..... 521

• Reiters syndrome ..... 522

• Systemic lupus erythematosus (SLE) ..... 522

• Systemic sclerosis ..... 524

• Crest syndrome ..... 524

• Sjogren's syndrome ..... 524

• Polymyositis/dermotomyositis ..... 525

• Fibromyalgin syndrome ..... 526

• Infectious bone diseases ..... 527

• Osteomyelitis ..... 527

• Low back pain ..... 529

• Degenerative disorders of spine ..... 531

• Management of spinal surgery ..... 533

• Scoliosis ..... 534

• Common hand and foot problems ..... 536

• Hand problems ..... 536

• Foot problems ..... 536

• Musculoskeletal tumors ..... 538

• Muscle tumors ..... 540

• Nursing management of bone tumor ..... 540

• Metabolic bone disease ..... 540

• Osteomalacia ..... 540

• Paget's disease ..... 541

• Osteoporosis ..... 542

12. Nursing Management of Immunological Problems ..... 545

• Introduction ..... 545

• Review of immune system ..... 545

• Primary immune aberrations and disease ..... 555

• Primary immunodeficiencies ..... 556

• Secondary immunodeficiencies ..... 557

• Multiple myeloma ..... 560

• Immediate hypersensitivity ..... 562

• Tissue-specific antibody hypersensitivity ..... 567

• Antigen-antibody complex hypersensitivity ..... 570

• T- cell mediated hypersensitivity ..... 571

• Stimulatory hypersensitivity ..... 572

• Chronic fatigue syndrome ..... 573

• HIV infection ..... 575

13. Nursing Management of Infectious Diseases ..... 592

• Introduction ..... 592
• The infection process ..... 592
• Standard precaution ..... 596
• The patient with an infectious disease ..... 598

14. Perioperative nursing ..... 602

• Introduction ..... 602
• Definition of the perioperative nursing and nurse ..... 602
• Scope of the perioperative nursing ..... 603
• Classification of surgical procedures ..... 603
• Role of nurse in perioperative care ..... 604
• General care ..... 604
• Preoperative care ..... 605
• Intraoperative care ..... 613
• Postoperative care ..... 622
• Discharge from the POCU ..... 634

15. Nursing management or disorders of eye ..... 636

• Introduction ..... 636
• Nursing assessment of the visual system ..... 636
• Diagnostic studies of the visual system ..... 640
• Visual impairment ..... 641
• Eye infections and inflammation ..... 645
• Eye trauma and injury ..... 646
• Glaucoma ..... 648
• Cataract ..... 651
• Retinal detachment ..... 652
• Strabismus ..... 654
• Eye tumors ..... 654

16. Nursing Management of Disorders of Ear, Nose and Throat ..... 657

• Introduction ..... 657

• Nursing assessment of auditory system ..... 657

• Diagnosis studies of auditory system ..... 658

• Hearing impairment ..... 659

• Disorder of external ear ..... 663

• Problems of middle ear and mastoid - ..... 664

• Perforated tympanic membrane ..... 664

• Otosclerosis ..... 664

• Otitis media ..... 665

• Problems of inner ear ..... 668

• Acoustic neuroma ..... 668

• Meniers disease ..... 669

• Disorder of nose and sinuses ..... 671

• Deviated septum ..... 671

• Nasal fracture ..... 672

• Rhinitis ..... 673

• Sinusitis ..... 676

• Disorder of throat ..... 678

• Acute pharyngitis ..... 678

• Acute follicular tonsilitis ..... 679

• Chronic enlargement of didenoids and tonsils ..... 679

• Acute laryngitis ..... 680

• Laryngeal paralysis ..... 681

• Tracheostomy ..... 682

17. Nursing Management of Neurological Disorders ..... 687

• Nursing assessment of the nervous system ..... 687
• Diagnostic studies of the nervous system ..... 694
• Intracranial problems ..... 696
• Altered level consciousness ..... 696
• Increased intracranial pressure ..... 702
• Head injury ..... 705
• Infections and inflammation of brain ..... 709
• Meningitis ..... 709
• Encephalitis ..... 710
• Brain abscess ..... 711
• Intracranial tumors ..... 711
• Spinal cord tumors ..... 713
• Cerebrovascular accident/stroke ..... 715
• Epilepsy/seizure disorder ..... 720
• Headache ..... 725
• Multiple sclerosis ..... 729
• Parkisons disease ..... 731
• Myasthenia gravis ..... 735
• Alzheimers disease ..... 737
• Amyotrophic lateral sclerosis ..... 738
• Guillain-barre syndrome ..... 739
• Trigeminal neuralgia ..... 741
• Bells palsy ..... 742
• Spinal cord injury ..... 743

18. Nursing Management of Oncological Conditions ..... 747

• Introduction ..... 747

• Cancer ..... 747

• Pathophysiology of cancer ..... 748

• Etiology of cancer ..... 751

• Classification of cancer ..... 753

• Prevention of cancer ..... 755

• Treatment of cancer ..... 758

• Surgery ..... 759

• Radiation therapy ..... 760

• Chemotherapy ..... 762

• Lung cancer-Ch 3 ..... 770

• Oral cancer-Ch 4 ..... 770

• Oesophageal carcinoma-Ch 4 ..... 770

• Cancer of stomach-Ch 4 ..... 770

• Colorectal cancer-Ch 4 ..... 770

• Cirrhosis of liver-Ch 4 ..... 770

• Leukemia-Ch 6 ..... 770

• Multiple myeloma-Ch 6 ..... 770

• Renal tumor-Ch 7 ..... 770

• Wilm's tumor-Ch 7 ..... 770

• Breast cancer-Ch 8 ..... 770

• Neoplasms of female RT-Ch 8 ..... 770

• Testicular cancer-Ch 8 ..... 770

• Caner of prostate-Ch 8 ..... 770

• Cancer of penis-Ch 8 ..... 770

• Eye tumor-Ch 15 ..... 770

• Musculoskeletal tumor-Ch 11 ..... 770

• Intracranial tumor-Ch 17 ..... 770

19. Management of Emergency and Disaster Nursing ..... 771

• Emergency nursing ..... 771
• Issues in emergency nursing care ..... 771
• Emergency nursing and continuum of care ..... 774
• Principle of emergency care ..... 774
• Disaster nursing ..... 776
• Hospital emergency preparedness plans ..... 777

20. Critical Care Nursing (CCN) ..... 781

• Evolution of critical care nursing ..... 781
• Critical care unit/ICU ..... 783
• Critical care patient ..... 784
• Problems related to family members ICU patient ..... 787
• Stressor in ICU ..... 788
• Ethical decision-making in CCN ..... 789
• Management of patient in critical care unit ..... 790 Index ..... 799

The history of medicine in India goes back through the centuries to about 3000 BC . The beginnings are shrouded in the mist of ancient myths. The experience and concern in health development date back to vedic period between 3000 BC and 1400 BC. The Indus Valley Civilization showed relics of planned cities and practice of environmental sanitation. According to Dr. Wheeler on the basis of his research studies from South, Arikamedu (Pondicherry) to North Mohenjodaro and Harappa, only one culture had been followed. An ideal healthful living of the people, such as every house of Mohenjodaro and Harappa had separate good water supply. In every backguard of the houses, there was a wide royal street and by the side of the street there was an arrangement of safe drinking water. Actually, this was followed by Dravidians who lived at that time. After the invasion of Aryans, the Dravidian got relegated to South. The specialist of pictograph reader, Father Heras says that it was a fact that ancient people of Mohenjodaro were protoDravidians, a fact also hinted by Sir John Marshall that there was a link between all that is the Dravidian culture, including Mohenjodaro and Karnataka. The Ayurveda and other system of medicine practised during this time suggests the development of comprehensive concept of health by the ancient sages of India.

Indian medicine is ancient. Its earliest concepts are set out in the sacred writings called the Vedas, especially in the metrical passages of the Atharvaved, which may possibly dates as far back as the second millennium

BC. According to a later writer, the system of medicine called Ayurveda was received by a saint Dhanvantari from Brahma, and Dhanvantari was defined as the God of medicine. In later times, his status was gradually reduced, until he was credited with having been an earthly king who died of snakebite. Legends tell of Dhanvantari's relations with snakes and illustrates the skill with which early Indian practitioners treated snakebite.

The period of Vedic medicine lasted until about 800 BC. The Vedas are rich in magical practices for the treatment of diseases and in charms for the expulsion of the demons traditionally supposed to cause diseases. The chief conditions mentioned are fever, cough, constipation, diarrhea, dropsy, abscesses, seizures, tumors and skin diseases (including leprosy). The herbs recommended for treatment are numerous.

The golden age of Indian medicine, from 800 BC until about 1000 AD may be termed the Brahmanistic period. It is marked especially by production of the medical treatises knwon respectively as the Charaka-Samhita and Sushruta-Samhita, attributed respectively to the physician Charaka and Susruta, traditionally a surgeon. Both these works were formerly regarded as being of great antiquity, and hence claims arose for the priority of Indian scientific medicine over its Greek counterpart.

Another school asserted that these works were written many centuries after the beginning of the Christian Era. The most recent estimates place the Charaka-Samhita its present form as dating from the Ist century AD, and there were earlier versions. The Sushruta-Samhita probably originated in the last

centuries of the pre-Christian Era and became fixed in its present form in the 7th century AD at the latest. Other medical treatises of lesser importance are those attributed to Vagbhata (8th century). All later treatises were based on these works.

Because the Hindus were prohibited by theirreligion from cutting the dead body, their knowledge of anatomy was limited. The Sushruta-Samhita recommends that a body be placed in a basket and sunk in a river for seven days. On its removal, the parts could be easily separated without cutting. As a result of these crude methods, the emphasis in Hindu anatomy was given to the bones, and then to the muscles, ligaments and joints. The nerves, blood vessels and internal organs were very imperfectly known.

The Hindus believed that the body contained three elementary substances, microcosmic representatives of the three divine universal forces, which they called spirit (air), phlegm, and bile. These were comparable with the humours of the Greeks. Health depends on the normal balance of these three elementary substances. The spirit has its seat below the navel the phlegm about the heart, and the bile between the heart and the navel. The seven primary constituents of the body-blood, flesh, fat, bone, marrow, chyle, and semen are produced by the action of the elementary substances. Semen was supposed to be produced from all parts of the body and not from any individual part or organ. Both Charaka and Sushruta state the existence of a large number of diseases (Susruta says 1,120). Rough classifications of diseases are given. In all texts "fever" of which numerous types are described, is regarded as important, phthisis (wasting disease, especially pulmonary tuberculosis) was apparently common, and the Hindu physicians knew the symptoms of cases likely to terminate fatally. Smallpox was common, and it is probable that smallpox inoculation was practised.

In diagnosis, the Hindu physicians used all five senses. Hearing was used to distinguish the nature of the breathing, alteration in voice, and the grinding sound produced by the rubbing together of broken ends of bones. They appear to have had a good clinical sense, and their sections on prognosis contain acute references to symptoms that are of grave import. Magical beliefs still persisted, however, until late in the classical period, the prognosis could be affected by such fortuitous factors as the cleanliness of the messenger sent to fetch the physician, the nature of his conveyance, or the types of persons whom the physician met on his journey to the patient.

Indian therapeutics was largely dietetic and medicinal. Dietetic treatment was important and preceded any medicinal treatment. Fats were mostly used internally and externally. The most important methods of active treatment were referred to as the "five procedures"; the administration emetics, purgatives, water enemas, oil enemas, and sneezing powders, inhalations were frequently employed, as were leeching, cupping and bleeding.

The Indian materia medica was extensive and consisted mainly of vegetable drugs, all of which were from indigenous plants. Charaka knew 500 medicinal plants, and Sushruta knew 700. But animal remedies (such as the milk of various animals, bones, gallstones) and minerals (sulfur, arsenic, lead, copper sulfate, gold) were also employed. The physicians collected and prepared their own vegetable drugs. Among those that eventually appeared in western pharmacopoeias are cardamom and cinnamon.

As a result of the strict religious beliefs of the Hindus, hygienic measures were important in treatment. Two meals a day were prescribed with indications of the nature of the diet, the amount of water to be drunk before and after the meal, and the use of condiments. Bathing and care of the skin were carefully prescribed, as were cleaning of the teeth with twigs from neem trees, anointing of the body with oil, and use of eyewashes.

In surgery, ancient Hindu medicine reached its zenith. Detailed instructions about the choice of instruments and the different operations are given in the classical texts. It has been said that the Hindus knew all ancient operations except the arrest of hemorrhage by the ligature. Their operations were grouped broadly as follows: excision of tumors; incision of abscesses, punctures of collections of fluid in the abdomen;

extraction of foreign bodies; pressing out of the contents of abscesses; probing of fistulas; and stitching of wound.

The surgical instruments used by the Hindus have received special attention in modern times. According to Sushruta, the surgeon should be equipped with 20 sharp and 101 blunt instruments. The sharp instruments included knives of various patterns, scissors, trocars (instruments for piercing tissues and draining fluid from them), saws and needles. The blunt instruments included forceps, specula (instruments for inspecting body cavities or passages), tubes, levers, hooks and probes. The Sushruta-Samhita does not mention the catheter, but it is referred to in later writings. The instruments were largely of steel. Alcohol seems to have been used as a narcotic during operations.

Especially in two types of operations the ancient Hindus were outstanding. Stone in the bladder (vesical calculus) was common in ancient India, and the surgeons frequently carried out the operation of lateral lithotomy for removal of the stones. They also introduced plastic surgery. Amputation of the nose was one of the prescribed punishments for adultery, and repair was carried out by cutting from the patient's cheek a piece of tissue of the required size and shape and applying it to the stump of the nose. The results appear to have been tolerably satisfactory, and the modern operation is certainly derived indirectly from this ancient source. The Hindu surgeons, also performed an operation for the cure of anal fistula and in this they were definitely in advance of the Greeks.

In the past there had been much speculation as to whether the Greek derived any of their medical knowledge from the Hindus. Mid-20th century opinion held that there was certainly intercommunication between Greece and India before the time of Alexander the Great.

A brief description of chronological events related to development of health and medicine in India is given below:

3000 BC: In the Indus Valley Civilisation, one finds evidence of well developed environmental sanitation programs such as underground drains public baths, etc. 'AROGYA' or 'Health' was given high priority in daily life and this concept of health included physical, mental, social and spiritual well-being.

2000 BC: Rigveda marks the beginning of the Indian system of medicine. Medicine was considered part of VEDAS or Scriptures. 'Ayurveda', a 'Science of life and art of living' said to be founded by Sage 'Atreya'. Good health implies an ideal balance between tridoshic factors, i.e. wind, bile, phlegm (Vata-Pitta and Kapha) according to Ayur-Veda. Health promotion and health education were also emphasized by following 'Dinacharya'. 1000 BC: Atharvaveda mentions the twin aims of medical sciences as health and longevity and curative treatment. Hygiene and dietetics are considered important in treatment. Beneficial effects of milk are described in detail.

800 BC: A codification of medical knowledge scattered through vedas by Bhela called Bhela-Samhita. 700 BC : A codification of medical knowledge by Agni-Vesa, said to be disciple of Atreya, called Agnivesa Samhita became the basis of later Charaka.

600 BC: A treatise by Kasyapa mainly dealing with paediatrics.

500 BC: 'Chivaravastu', a book written by unknown author is found. It mentions prince Jivika, the court physician of Bimbasara, King of Magadh, as a marvellous physician and surgeon. He is credited with such difficult operations as piercing the skull to operate on the brain, surgery of the eyes, etc. and medical treatment of dropsy, internal tumors and varicose veins.

272 BC-236 BC: King Asoka, a convert to Buddhism, built number of hospitals. More emphasis was laid on the preventive aspects. Doctors, nurses, and midwives were to be trustworthy and skillful. The nurses were usually men and old women. This period saw famous medical schools at Taxila and Nalanda.

237 BC-201 BC: St. Buddha instituted a state medical system, appointed doctors for every 10 villages on the main roads of India. Pharmaceutical gardens were also maintained.

200 BC-100 BC: Patanjali explored the yoga system of philosophy of men and physical discipline-the starting point of yoga therapy later continued.

100 BC: Charaka-Samhita, the first classical exposition of Indian system medicine deals with an almost all the branches of medicine, anatomy, physiology, etiology, prognosis, pathology, treatment procedure, and sequence of medication and an extension Materia Medica for more than 600 drugs. This treatise formed the basis of the Atreya School of Medicine in India, in (100) AD. The qualification of attending nurse, enshrined in the Charaka-Samhita, i.e. knowledge of preparation and compounding of drugs for administration, cleverness, devotedness to patient under care and purity of both mind and body.

200-300 AD: Sushruta-Samhita appears to have been revised by Nagarjuna, laid main emphasis on surgery. This great treatise described more than 300 operations, 43 different surgical processes and 121 different types of instruments. The Materia Medica is also extensive covering more than 650 drugs of animals, plant and mineral origin. This treatise forms the basis of Dhanwantari School (300 AD).

Sushruta defines ideal relations of doctor, patient, nurses and medicine as the four feet upon which a cure must rest.

500-600 AD: Vagbhata wrote Astanga Hridaya ( 8 limbs and heart). The eight limbs refer to the eight traditional branches of Ayurvedic knowledge, i.e. therapeutics, surgery, ENT, mental and superstitious diseases, infantile diseases and treatment, toxicology, arresting physical and mental decay, and rejuvenation or regaining lost virility potency and procreative ability.

This book is the most concise and scientific exposition of Ayurveda. It is in verse form, making it easy to memorise. It incorporates the teachings of the sages Atreya and Dhan-Wantari and the Rasayana school of medicine. It is distinguished butits knowledge of chemical reactions and laboratory processes. This book has been translated into foreign language.

600-800 AD: Sodhala ( 700 AD ) two treatises, Gandani-ghraha, a medical treatise and Sodhala a medical Lexicon.

Vrudukunta ( 750 AD ) writes Siddayoga, the earliest treatise on Rasa Chikitsa now existing intact. The Rasa Chikitsa system considers mercury as the king of all medicines. Siddayoga explain the various preparations of mercury and other metals, alloys, metallic compounds, salts and sulphur. This school of medicine is called SIDDHA school. All of them are made of metals, salts and sulphur. It is supposed to be a continuation of the pre-Aryan medical system in India. It is popular in Eastern and Southern India.

Siddha Nagarjuna two treatises on the Siddha systems, Rasarathanakara and Arogya Manjari. Madhavacharya (700-800 AD) wrote Madhava Nidana. This is a compilation from the earlier works of Agnivesa, Charaka, Sushruta, Vagbhata. It is specially useful as a chemical guide to preparations. It is famous allover India as the best Ayurvedic work on the diagnosis of diseases.

800-1300 AD: A number of treatises were written in India during this period. Arkaprakasha, a book on tincture extraction, Sarangadhara Samhita, Chikitsa, Sangraha and Yoga Ratnakara are the better known among them.

The period also witnessed a spirit of writing on the Rasa Chikitsa system. Rasha Hridaya by Govind Vagbhata, Rasaratnakara by Siddha Nityananda, Rasara-Tnasammukta by Vagbhata (another), Rasarnava by Sambhu, Rasendrachintamani by Ramachandra, and Rasendra Choodamani by Somadeva.

1300-1600 AD: Bhavamisra wrote Bhava Pra-Kasha. This is the most renowned Indian treatise during the period. It contains an exhaustive list of diseases and their symptoms and complete list of drugs including many not mentioned in the earlier works. It includes etiology and treatment of syphilis, a disease brought into India by Portuguese seamen.

Other works of this period are Chikitsaliye by Trisata, a manual on diagnosis; Chintamani by Ballbhendra on aetiology and diagnosis; and Vaidyamrutha by Moreswara on the treatment of diseases.

Another class of works produced during this period are Medical Lexicons by Madanapala, Nagahari, Bimapala, and Rajavallabha.

1600: East India Company established British Rule in India. Western medicine and surgery started to be practised and became popular in India.

In the past, the progress of nursing in India has been hindered by many difficulties, such as: the low status of women, the system of purdah among Muslim women, the caste system among Hindus, illiteracy, poverty, political unrest, language differences, and the fact that nursing has been looked upon as servant's work.

Since Independence day 1947, many changes have taken place and the attitude towards nursing is changing. More women are being educated and many are taking up nursing as their profession.

We have very little information about medicine and nursing in India until the 15th century, when Vasoco da Gama came to India. He set up trading posts on the west coast. Franciscan, Dominican and Jesuit missionaries came to minister to the sick and needy. The Portuguese set up European type of dispensaries at Goa and Madras and physicians from Europe were invited to India. One of these, Garcia da Orta, in 1550 wrote "Simples Drugs of India".

Military nursing was the earliest type of nursing. In 1664, the East India Company helped to start a hospital for soldiers at Fort St. George, Madras. Later, acivilian hospital was built and the medical staff, appointed by the East India Company, served in both hospitals. In 1797, a Lying-in-Hospital was built and in 1854 the government sanctioned a training school for midwives. In 1861, through the efforts of Miss Nightingale, reforms in military hospitals led to reforms in civil hospitals. Efforts were made to provide health services for the people of India. This laid the foundation for public health nursing.

Nursing in the military hospitals was of poor quality carried on by male orderlies and menial staff. In 1871 the Government General Hospital, Madras undertook a plan to train nurses. Nurses were brought from England to be in-charge and the first six students were those who had previously received their diploma in midwifery. Later this plan was reversed. General training was taken first followed by a course in midwifery.

In Bombay, among the one of the earliest hospitals is the Jamsetjee Jeejeebhoy group, the first of which was opened in 1843. Another hospital which was to play an important part in the development of modern nursing in India was the Pestani Hormusji Cama Hospital for women and children, which was founded in 1883 but not opened until 1886.

Provision for the nursing care of patients in these early hospitals was very limited. In the JJ Group, nursing was done by medical students and menials until 1868 when the government invited the Sisters of the Community of All Saints to come from England and take over the work of nursing. Their work was appreciated and the need for training nurses was felt. At this time, it was difficult to get nurses. There were only a few Anglo-Indian and Indian Christian girls working in mission hospitals. The sisters of all saints took the first steps to establish a training school for nurses in this hospital. In 1891, Bai Kashibai Ganpat was the first Indian nurse to come for training. Training was at first two years but became three years when the Bombay Presidency Nursing Association was established in 1909.

An outstanding graduate of the JJ Group of hospitals was Miss. TK Adranvala. After her graduation, she worked as a ward sister, then became assistant Matron under the sisters and finally, superintendent of the hospitals. She held this position until she was asked to accept the position of Nursing Superintendent and Nurse adviser to the Government of India. She remained in this position until retiring in 1966. She continues active participation in nursing as a WHO representative in Nepal. Miss Adranvala has worked very hard to raise the status of the nursing profession in India. She has given much of her time to the interests of the TNAI having held the office of president for two terms and that of treasurer until she was released at her own request. The nursing profession in India is fortunate to have had such a capable person as Miss Adranvala as its representative in the World Health Organization. She is highly respected by all and many seek her wise counsel.

Mission Hospitals were the first to begin the training of Indians as nurses, very gradually overcoming the

prejudices of parents against sending their girls for a training which was felt to be beneath the dignity of decent educated girls. Religion prevented Hindu and Muslim girls from joining at all and so only Christian girls could be trained at first. But for many years, even they felt nursing was an inferior profession.

In the beginning there was no uniformity of courses or educational requirements. About 1907-1910 the North India United Board of Examiners for Mission Hospitals was organized and set up rules for admissions and standards of training and conducted a public examination. On 24th May 1909 the Indian Medical Mission Association granted the Nursing Diploma after examining student by Central Board for Nurses' Training Schools in South India. A few years later the Mid-India and the South India Boards of Nurse examiners were similarly set up. These are Examining Boards of the Nurses' League of the Christian Medical Association of India. The name of the South India Board was changed to 'The Board of Nursing Education, Nurses' League of Christian Medical Association of India branch in 1975.

Until the late 19th century there were no women doctors and therefore, no care for women except in mission hospitals. This fact was brought to the attention of Queen Victoria. At this time, Lady Dufferin was coming out to India with her husband who was on government service. Queen Victoria instructed Lady Dufferin about the need for medical care for women and children in India and asked her to take a special interest in this problem. Lady Dufferin wrote to her friends and influential people to get financial aid. Thus, in 1885, Lady Dufferin was responsible for starting the 'National Association for supplying Medical Aid by Women to Women of India'. This is commonly called the Dufferin Fund and continues to provide medical education for women, to train nurses and midwives for hospitals and private work, and to improve medical facilities for women.

Between 1890 and 1900, many schools under either missions or government were started in various parts of India. The directors fo these schools were English or American. Each school sets up its own pattern of training familiar to the director. There was a need for systematic training of nurses like that given in the Nightingale School in England. Thus it was, that in 1886, money from the Dufferin Fund was made available for this purpose. Miss Atkinson, a Nightingale nurse, was brought out from England to Bombay to set up and be the superintendent of the First Modern Training School for Nurses in India. The school was established in the Cama Hospital for Women and Children in 1891. It began with a one year course but by 1995 it had been extended to three years.

The leaders of nursing in India realized that more and better qualified teachers and ward supervisors were needed if standards were to be maintained and nursing was to advance. Hence, courses were set up in several places to give Indian nurses an opportunity to prepare themselves for responsible positions in hospitals and schools of nursing. Post-certificate courses were first offered in nursing administration, supervision and teaching. These originated at the College of Nursing, New Delhi; the College of Nursing, CMC Hospital Vellore and the Government General Hospital, Madras.

The first four year basic bachelor degree programmes were established in 1946 at the Colleges of Nursing in Delhi and Vellore. This programme is now offered in a number of other colleges.

In 1963, the School of Nursing in Thiruvananthapuram instituted the first two year post-certificate bachelor degree programme. Other schools have begun this programme since that time.

In recent years, as higher education for nurses has developed around the world, courses in India have developed so that the nurse can specialize in almost any subject and continue education through the level of the Master's degree. The first Master's degree course, a two-year postgraduate programme was begun in 1960 at the College of Nursing in Delhi. (Now Rajkumari Amrit Kaur College of Nursing, New Delhi110 024). In 1970, many colleges of nursing were started and offering PCBSc Nursing and Basic BSc Nursing courses in various parts of India. In Karnataka, Bangalore University instituted Ph D programme for nurses in 1991. The author of this book is the first person to get Doctoral degree in Nursing in the State of Karnataka.

The use of auxiliary nursing personnel to ease the shortage of professional nurses had been common in some countries when it was first put into practice in India. A two-year programme for the Auxiliary NurseMidwife was first established in 1951 at St. Mary's Hospital, Tarn Taran in Punjab state. By 1962, there were 263 courses being offered in India. The auxiliary nurse midwife is prepared to practise elementary nursing and full midwifery. She functions primarily in the community rather than the hospital. The practice of the auxiliary nurse-midwife has helped to improve the amount of care given to the patient as well as the health teaching given to the public. In 1977 the ANM course was completely revised by the Indian Nursing Council and expanded to include sociology health education and communication skills and subjects necessary to equip the multipurpose health worker/ ANM to serve effectively as a primary health care worker in the community. Such workers are key persons for achievement of the goal of 'Health for all by 2000 AD " to which we in India are committed.

One of the handicaps in the development of nursing schools was the lack of textbooks. In other countries books had been written by doctors and nurses. Some of these were translated into the vernacular for the early schools and colleges. Many English and American textbooks are being used in the schools today. There is a great need for textbooks which have been written by Indian nurses. A beginning had been made in this work and the first Textbook for Nurses in India was printed by the South India Examining Board of the Nurses' League of the Christian Medical Association of India in 1941. The Nurses' League has also directed the publishing of a Textbook For Auxiliary Nurse-Midwives, first printed in 1967. This book was completely revised and published in two volumes in 1985 as a Textbook For The Health Worker (ANM) to meet the needs of the health worker. Several manuals related to the basic sciences and nursing have been published by other professional nursing bodies. Although progress has been made in the publication of textbooks by the nurses of India, there remains a wide area of subjects which have not been touched upon and the general need for more and varied textbooks continues. Since a few nursing educator started writing texts on Nursing, to quote, Late Dr. (Mrs) Kasturi Sunder Rao wrote text on 'Community Health Nursing, and a few Bombaybased Nurses made an effort to write guides and two books on Nursing. In later part of 1990s onwards the author of this book also has written on 'Nursing Research' (1998), Community Health Nursing (1998), Nursing Administration(2000), Nursing Education (2003), Fundamentals of Nursing (2002) Medical surgical Nursing (2003), Pediatric Child Health Nursing (2004), Midwifery and Reproductory Health Nursing (2006), Psychiatric Mental Health Nursing (2006), Nursing Theories (2007), on the basis of present needs in Indian context and started revision of earlier text and Essential series of all the books also availble are written by author.

Nursing education in India began with very brief periods of training as mentioned in the first part of this chapter. Orderlies and midwives were often chosen for this and were given a period of two to six months of closely supervised practical experience in general nursing, then called 'sick nursing'. This was training in the hospital, and certificates were given after completion of a training.

The basic Program for combined general nursing and midwifery developed rapidly after 1871. The need for theory as well as practical experience was felt. The training for general nursing was extended to two years and then three years before the student went on for midwifery training. The present basic program for nursing education throughout India consists of a three and half year program in general nursing and six to seven months in midwifery. Uniformity of training is maintained by recognition of schools which meet the standards and requirements given by the Indian Nursing Council. The basic certificate program now includes all areas of nursing as integrated community health nursing.

Now, most of the states in India started basic B.Sc Nursing, Postcertificate B.Sc Nursing and M.Sc Nursing degree courses in their related universities. And also there is Doctoral degree course in nursing leading to Ph.D in nursing.

As training for nurses, midwives, and health visitors progressed, the need for legislation to provide basic minimum standards in education and training was felt. It was also felt that registration would give greater professional status. For some years, nurses struggled to obtain proper examinations and examiners and registration for nurses. In 1926 Madras State formed the first Registration Council. While most states now have a recognized Registration Council, all do not. It is now possible for the students of all schools in India to be registered in one of the State Registration Councils.

The Indian Nursing Council Act was passed by an ordinance on December 31st 1947. The council was constituted in 1949. The purpose of the council is to co-ordinate activities of the various State Registration Councils, to set up standards for nursing education and to make sure these standards are carried out. Before this time, nurses registered in one state were not necessarily recognised for registration in another. The condition to mutual recognition by the State Nurses Registration Council called reciprocity was possible only if uniform standards of nursing education was maintained. Therefore, the INC was given authority to prescribe curricula for nursing education in all of the states. At the same time, it was given authority to recognize programmes of nursing education or refuse recognition. The Indian Nursing Council is not itself a registering body nor examining body but it can enforce its standards by recognizing or refusing to recognize schools. And now almost all the states of India has their State Nursing Council for example, Karnataka State Nursing Council, etc....

In India community health nursing had its beginning when the terrible conditions under which children were born were recognized as a cause for the high civilian mortality rate. It was realized that the untrained dais who attended women during delivery must be given training. This was not an easy job as the dais were unwilling to be trained and the patients were very willing to accept the old customary methods and could see no need to change. The first attempts to train dais were carried out by missionaries as early as 1886. In 1900, Lady Curzon brought about the establishment of the Victoria Memorial Scholarship for the purpose of improving safe delivery practices. The need for training a better type of midwife was felt. In this, Madras State led the way when they passed the Madras Registration of Nurses and Midwives Act of 1926.

Slowly the need for trained personnel for maternal and childhealth, as part of community health nursing was felt. To supply this need a Health School for the training of health visitors was started in Delhi in 1918. This has now become the Lady Reading Health School.

A further step forward was taken in 1948, when community health nursing was integrated in the basic programme of the new degree courses which were started at the College of Nursing, Delhi and the School of Nursing, CMC Hospital, Vellore under the University of Delhi and Madras respectively.

Since 1953, a post-certificate course in community health nursing has been given at the All India Institute of Hygiene and Public Health in Calcutta. In 1960, a course was established by the Lady Reading Health School in Delhi. Several other schools now offer this programme.

To prepare more community Health nurses, in 1957 the Government of India selected ten schools of nursing and gave assistance so that they could integrate community health nursing into their basic course. Since that time, recognition of a programme of basic nursing education required that community health nursing be integrated into the basic course. Thus, all professional nurses today can function in the hospital and the community at the level of a staff nurse.

Various international organizations, such as WHO, UNICEF and Colombo Plan have assisted by supplying trained personnel and equipment to help in the training of students in the rural field, maternity work and paediatrics.

Throughout this study of nursing we have seen nursing advance from the kindly ministrations of a mother or

a neighbour to the highly organized service of today. In the beginning individuals were inspired to help one another in distress. This essential care or service still remains but time has brought about changes in our ideas regarding nursing. Today we are not only relieve and give comfort but help our patients to live upto their optimum health. The new emphasis is on health nursingnursing the mind, the family as a whole and as part of the community with the nurse as the health teacher.

Growing specialisation in medicine is resulting in a trend towards increased specialisation in nursing. The development of new tests and diagnostic procedures, new medicines and new equipment make specialisation even more necessary as the amount of scientific knowledge needed for a certain speciality becomes greater. Developments in other professions also influence trends in the nursing profession. As other members of the health team become more available and more highly specialized, the work of the nurse is changing towards more specific nursing functions. It has also added to the number and kind of professional relationships which must be maintained by the nurse. The power of spiritual factors is becoming of increasing interest as reports of the healing power of spiritual activity such as meditation is receiving more attention. Just as advances in technology tend to take the nurse away from the bedside and a direct relationship with the patient, so these developments are showing the need for a deeper therapeutic relationship between the nurse and the patient. The future will demand a balance of these factors in order to meet the total health needs of the individual and the community. Future trends are likely to show an effort to make this balance.

Many trends leading to professionalism are taking place because of the untiring efforts of nurses dedicated to achieving the aim of becoming a profession. In 1970, WHO recognized Nursing as a profession. It has often been a difficult struggle requiring real courage and vision by nursing leaders in the face of serious obstacles. Today nurses enjoy many rights and privileges, though desired standards are still not achieved in all areas, because nursing leaders have struggled to achieve them. Nurses who are going to be the future leaders have to carry on this work of greater achievement through growing amounts of writing and research.

Nursing today provides an ever widening scope of opportunity for service. With present trends leading towards greater opportunities, varieties of services and growing social and professional recognition, it should be exciting and challenging for nurses to know that all nurses members of this profession since they fulfill the criteria of the profession. (for further details please read the authors text on "NURSING ADMINISTRATION", 2nd Edition.)

Medical Surgical Nursing Medical-Surgical nursing is commonly defined as the nursing care of adults with suspected or diagnosed pathology of physiological function. It encompasses such a large scope that the trend is to subdivide medical-Surgical, Oncological (cancer) nursing, and only recently have the other specialties been developed.

Currently, all basic nursing programs prepare nurses to practice medical-surgical nursing. Advanced preparation at the master's and doctoral levels is necessary if the nurse wishes to devlop expertise and acquire in-depth knowledge in particular aspects or subdivisions of the specialty. These specialties would include intensive care units, the emergency room.

Medical-surgical nursing is the area of practice concerned with the care of adults with predicted or exisiting physiologic alterations, trauma, or disability. It is the backbone of modern nursing and the practice foundation of virtually all health care institutions.

Traditionally medical-surgical nursing was not considered a specialty area. Rather, practices with a focus on a specific type of health problem within the area of medical-surgical nursing were considered specialties. These included cardiovascular, perioperative, neurologic, gynecologic, infection control and emergency nursing, and practices limited to problems such as wound care, burns, hypertension and diabetes. Today this view has changed. Medicalsurgical nursing is now formally recognized as a specialty in its own right, and the focused practice areas are seen as subspecialties.

Formal recognition as a specialty means that a practice area meets the criteria for specialty status, which were published in the document titled "Recognition of a Specialty Approval of Scope" Statements and Acknowledgement of Nursing practice Standards (ANA).

The criteria are that the practice area must:

• Be clearly defined and subscribe to the overall purposes and functions of nursing
• Define itself as nursing
• Adhere to the overall licensure requirements of the profession
• Be national or international in scope
• Be able to identify a need and demand for itself
• Have a well-derived knowledge base particular to the practice of the specialty
• Be organized and represented by a national specialty association
• Be concerned with phenomena within the discipline of nursing
• Have defined competencies for the area of specialty practice
• Have existing mechanisms for supporting, reviewing and disseminating research to support its knowledge base
• Have continuing education programs that prepare nurses in the specialty
• Include a substantial number of nurses who devote most of their practice to the specialty The nursing profession has adopted standards of practice that describe the responsibilities for which are accountable. All nurses, regardless of education, Standards of Clinical Nursing Practice to guide their practice. This broad set of standards has two components: standards of care and standards of professional performance. The nursing process and competent level of nursing care are the foundation of the standards of care. The standards of professional performance address expected quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization. Each standard has measurement criteria to demonstrate competent practice.

The Academy of Medical Surgical Nurses, founded in 1991, is an international organization dedicated to fostering excellence in medical-surgical nursing practice. Its mission is to "enhance the clinical expertise, professionalism, and leadership of nurse's caring for adults in hospitals, the community, and long-term care."

Health is a state of well-being of individual and community. So it can be examined at individual or community level. For individual the term 'health' refers to the optimal functioning of the individual, absence of disease, illness, impairment or injury. In the context of the community it refers to various objective measures of health, health status or health indices like incidence of, and prevalence of disease applied to different segments of population. Defining good health is difficult, because each person has personal concept of health.

The definition of health range on a continuum from the absence of diseases to optimal functioning to utopian ideals of complete state of physical, mental, emotional, spiritual and social well-being.

About 500 BC, Pericles defined 'health' as "That state of moral, mental and physical well-being which enables a person to face any crisis in life with the utmost grace (of God) and facility."

HS Hayman defines health as a state of feeling sound in body, mind and spirit, with a sense of reserve power. This perception, if health is based on normal functioning of the body's physiological process, understanding the principles of healthful living and attitude that regards health not only as a means of survival and self-fulfilment in itself, but as means to a creative social adjustment and a richer, fuller life as measured in constructive service to mankind.

H Blum defines 'health' as the person's capacity to function in a way to maximise potential, to maintain a balance appropriate to age and social needs, to be reasonably free of gross dissatisfaction, discomfort, disease or disability, and to behave in ways that promote survival as well as self-fulfilment or enjoyment.

• Health is the condition of being sound in body, mind or spirit especially freedom from physical disease or pain (Webber).
• Health refer to a "soundness of body or mind; that condition in which its functions are duly and efficiently discharged (Oxford English Dictionary).
• Health is a condition or quality of the human organism expressing the adequate functioning of the organising the given conditions, genetic and environmental.
• Health is a modes vivondi enabling imperfect men to achieve a rewarding and not too painful existence while they cope with an imperfect world.

$\boldsymbol{R}$ Dubiois views 'health' as adaptation a function of adjustment. He believes an (WHO's) utopian state of health can never be reached because the person can never be so perfectly adapted to the environment that life will not involve struggle, failure and suffering. Humans can adapt to environmental conditions or change the environment but each new adaptation produces new problems that demand new solution. "Health is the achievement of a state of harmony between man's internal and external milieu" (Liverpool School of Tropical Medicine). $\boldsymbol{F}$ and $\boldsymbol{E}$ Rathbone formulates health as a wholeness of function, movement towards self actualisation, relating to effective, creative use of potential, realistic interpretation of experiences and co-ordination of attitudinal, physiological and behavioural adaptations.

Imogene King defined 'health' as a dynamic state in the life cycle of an organism that implies continuous adaptation to stresses in the internal and external environment through optimum use of one's resources to achieve maximum potential for daily living.

According to $\boldsymbol{S}$ Perkin "health is a state of relative equilibrium of body form and functions which results from its successful, dynamic adjustment to forces tending to disturb it. It is not passive interplay between body substance and forces infringing upon it, but an active response of the body forces working towards adjustment.

Health is wellness of an individual. According to Dunn the term 'high level wellness' implies wellbeing in degree or level.

High level wellness for the individual is defined as an integrated method of functioning which is oriented towards maximising the potential of which the individual is capable. It requires that an individual maintains a continuous balance and purposeful direction within the environment whereby he is functioning.

WHO defines "Health as state of complete physical, mental, social and spiritual well-being and not merely absence of disease."

This definition is positive and includes more than physical health, it infers that health is an absolute or ultimate state. But all individuals cannot achieve the same level of health because of innate differences, some of us are born with severe physical and mental limitations. So according to WHO, the complete wellbeing for all is unattainable goal. Hence, the U.S.

President's Commission stated, "health means an optimum state of physical, mental and' social wellbeing."

Terris $\boldsymbol{M}$, a famous epidemiologist believes the WHO definition should be re-worded as "Health is a state of physical, mental and social well-being and ability to function and not merely the absence of 'illness' or infirmity." Thereby replacing 'disease' by illness and excluding 'complete' as health is not an absolute. The addition of "and ability to function" is necessary, as a definition of health requires both objective and subjective components. The objective component being the "ability to function," the subjective being "feeling of well-being."

A singular definition, and one which returns more to Pericles' version is that of the Liverpool School of Tropical Medicine: "Health is the achievement of a state of harmony between man's internal and external milieu."

However, WHO's definition has the following characteristics that promote a more positive concept of health.

1. A concern for the individual as a total system.
2. A view of health that identifies internal and external environment.
3. An acknowledgement of the importance of an individual's role in life. Health is a changing, evolving concept that is basic to nursing. For centuries, the concept of disease was the yardstick by which health was measured. Now there has been an increasing emphasis on health. Health is very difficult to define. There is no consensus about any definitions of health. There is no consensus about any definitions of health. There is knowledge of how to attain a certain level of health, but health itself cannot be measured.

Health is described in various sources as a value judgment, a subjective state, a relative concept, a spectrum, a cycle, a process, and as an abstraction that cannot be measured objectively. In many definitions physiological and psychological components of health are dichotomised. Other subconcepts that might be included in definitions of health include environmental and social influences (economical or financial), freedom of pain or disease, optimum capability, ability to adapt, purposeful direction and meaning in life, and harmony, balance, or sense of well-being.

Historically, health and illness were viewed as extremes on a continuum, with the absence of clinically recognisable disease being equated with the presence of health. In 1974 World Health Organization defined health in terms of total well-being and discouraged the conceptualisation of health as simply the absence of diseases. At the time, some considered this definition impractical; some viewed it as a possible goal for all people, while others consider complete well-being unobtainable. However this definition of health includes three characteristics of basic to a positive concept of health:

• It refers concern for the individual as a total person rather than a merely the sum of various parts
• It places health in the context of environment
• It equates health with productive and creative living.
• The harmonious balance of the state of physical, mental, social and spiritual well-being of the human individual integrated into his health and constitutes health. The state of positive health implies the notion of "perfect functioning" of the body and mind. It conceptualise health biologically as a state in which every cell and every organ is functioning at optimum capacity and in perfect harmony with the rest of the body; psychologically, as a state in which the individuals feels a sense of perfect well-being and of mastery over his environment; socially, as a state in which the individual capacity for participation in the social system are optional, and spiritually, as state in which the individual which reaches out and strives for meaning and purpose in life.

The concept of perfect positive health cannot become a reality because man will never be so perfectly adapted to his environment that his life will not involve struggle, failure, and suffering positive health will therefore, always remain a mirage because every thing in life is subject to change. So health is a dynamic state of physical, mental, social, and spiritual well-being of an individual, not merely an absence of disease or infirmity.

More contemporary definitions of health have emphasized the relationship between health and wellness. Although health may be viewed as a static state of being at any given point of time, wellness is the process of moving toward integration of human functioning; maximisation of human potential; selfresponsibility for health; greater awareness of selfsatisfaction; and wholeness in body, mind and spirit.

Illness is a highly personal state in which the person feels unhealthy or ill. Illness may or may not be related to disease. An individual could have a disease, for example, a growth in the stomach, and not feel ill. Parsons defines illness as "a state of disturbance in the normal functioning of the total human individual, including both the state of the organism as a biological system, and of his person and social adjustments."

Sickness is a status or social entity that is usually associated with disease or illness but can occur independently of them. When a person is defined as sick, several dependent behaviours are accepted that otherwise might be considered unacceptable. Bauman found that people use three distinct criteria to determine whether they are ill:

1. The presence of symptoms, such as elevated temperature or pain.
2. Their perceptions of how they feel; for example, good, bad, sick.
3. Their ability to carry out daily activities, such as job or schoolwork. Disease can be described as an alteration in body functions resulting in a reduction of capacities or a shortening of the normal life span. Disease may further be described as acute or chronic, communicable, congenital, degenerative, functional, malignant, psychosomatic, or idiopathic. Intervention by physicians has the goal of eliminating or ameliorating disease processes. Primitive people thought disease was caused by "forces" or spirits. Later, this belief was replaced by the single causation theory. Increasingly, a number of factors are considered to interact in causing disease and determining the individual's response to treatment.

The causation of disease is called its etiology. A description of the etiology of a disease includes the identification of all causal factors that act together to bring about the particular disease. For example, the tubercle bacillus is designated as the biologic agent of tuberculosis. However, other etiologic factors, such as age, nutritional status, and even occupation, are

involved in the development of tuberculosis and influence the course of infection.

Risk factors are situations, habits, or other phenomena that increase a person's vulnerability to illness or injury. Risk factors can be categorized into five interrelated areas: genetic makeup, age, physiologic factors, life-style, and environment: Examples of each follow:

• Genetic makeup: A person with a family history of diabetes mellitus or cancer is at risk of developing the disease later in life.
• Age: The risk of birth defects and complications of pregnancy increases after age 35; the risk of communicable disease is higher in school age children; and the risk of cardiovascular disease increases with age for both sexes.
• Physiologic factors: Pregnancy places the fetus and mother at increased risk of disease; obesity increases the risk of heart disease.
• Lifestyle or health habits: Overeating increases the risk of heart disease; smoking increases the risk of lung cancer; poor nutrition leads to several deficiencies; promiscuity increases the risk of sexually transmitted disease; excessive use of alcohol increases the risk of accident, liver disease, and disability; unabated stress increases the risk of accidents and illness; and certain activities such as skiing or mountain climbing increase the risk of injury.
• Environment: Exposure to specific hazards, such as asbestos, rubber, and plastic, increases the risk of certain kinds of cancer; unclean, overcrowded living conditions predispose people to infections and other communicable diseases; air, water, and noise pollution all increase susceptibility to illness. All of these risks present challenges to health care workers, especially nurses, in terms of prevention. Measures to enhance health include maintaining ideal body weight; eating regular meals with few snacks; elimination of cigarette smoking; moderation of alcohol consumption; safety measures, such as using seat belts, to prevent accidents and injuries; and periodic screening for such health problems as cancer.

Health field concept view, all causes of death and disease have four contributing elements: (a) human biologic factors, such as genetic makeup and age; (b) behavioral factors or unhealthy life-styles; (c) environmental hazards; and (d) inadequacies in the health care system. Using these four elements as a framework, a group of experts devised a method to assess the relative contributions of each of these elements to the ten leading causes of death. The results indicated that approximately $50 \%$ of deaths were due to unhealthy behavior or life-style; $20 \%$ to human biologic factors; $20 \%$ to environmental factors; and $10 \%$ to inadequacies in health care. These results have implications for nursing; the most important is that a substantial number of deaths could be avoided by efforts directed at health promotion and illness prevention.

Traditionally, medical practitioners have dealt with disease at a subsystem level. Subsystems are those aspects of the body subsystemed in the larger system of the whole body. A subsystem may be a cell, an organ, or an organ system. Only recently medical practitioners started looking at the person as an entity, or whole. Nurses, by contrast, have traditionally viewed the person as an entity, taking a holistic view of people. Nursing practice today is based on the multiple causation theory of health problems. Unemployment, pollution, lifestyle, and stressful events, while not disease, may all contribute to illness. These can be considered suprasystem problems, i.e., problems stemming from systems in which the individual is a subsystem. Thus, the concept of illness must include all aspects of the total person as well as the biologic and genetic factors that contribute to disease. Illness, then, is influenced by a person's family, social network, environment, and culture.

Illness behaviour is "any activity, undertaken by a person who feels ill, to define the state of his health and to discover a suitable remedy." Illness behaviour depends on the way in which the person perceives illness, and it is selectively affected by multiple modifiers of patterning. For example, age, gender, occupation, socioeconomic status, religion, ethnicity, psychological stability, personality, education, meaning attached to symptoms, methods of coping with anxiety, attitude toward self, prior health-illness experiences, availability of resources, and degree, type, and duration of current stress situations are all factors that may be related to illness behaviour.

Various scientists have described the stages of illness. By knowing these stages and the illness behaviors that accompany them, nurses can better understand their clients' behaviour and determine ways to assist them. Illness behaviour is "any activity undertaken by a person who feels ill, to define the state of his health and to discover a suitable remedy." How people behave when they are ill is affected by many variables, such as age, sex, occupation, socioeconomic status, religion, ethnic origin, psychologic stability, personality, education and modes of coping. Such man describes five stages of illness as given below:

The symptom experience stage is the transition stage during which people come to believe something is wrong. Either a significant person mentions that they look unwell, or people experience some symptoms, which can appear insidiously. The symptom experience stage has three aspects:

• The physical experience of symptoms (e.g., pain or elevated temperature)
• The cognitive aspect (the interpretation of the symptoms in terms that have some meaning to the person)
• The emotional response (e.g., fear or anxiety).

During this stage, unwell persons usually consult others close to them about their symptoms or feelings. People validate with their spouses or support persons that the symptoms are real. At this stage, sick persons sometimes try home remedies, such as laxatives or cough medicines.

The second stage signals acceptance of tile illness. At this time, individuals decide that their symptoms or concerns are sufficiently severe to suggest that they are sick. Some people seek professional help quickly; others continue self-treatment, often following the suggestions of family and friends.

In this stage, sick people are usually afraid, but they now accept that they are ill even though they may not be able to accept the possible reasons. In conferring with people close to them, sick people seek not only advice but also support for the decision to give up some activities and, for example, stay home from work.

At the end of this stage, sick people experience one of two outcomes. They may find that the symptoms have changed and that they feel better. If family members support the perceptions of such persons, they are no longer considered or consider themselves sick. Then the recovered persons resume normal obligations, such as returning to work or attending a school concert.

If, however, the symptoms persist or increase and if lack of improvement is validated by the family or significant others, then sick people know they should seek some treatment. The choice of a treatment plan is often affected by the known available alternatives and previous experience.

Sick people seek the advice of a health professional either on their own initiative or at the urging of significant others. When people go for professional advice they are really asking for three types of information:

• Validation of real illness
• Explanation of the symptoms in understandable terms
• Reassurance that they will be all right or prediction of what the outcome will be. If the health professional does not validate illness, people have two recourses: to return to normal activities or to seek other advice. If the symptoms disappear, people often perceive that they really are not ill. If symptoms continue, people usually return to the health professional or go to a second person for care. People who are repeatedly told that they are not ill, may seek out quasi practitioners as a last resort to alleviate the perceived symptoms. Some people will go from health professional to health professional until they find someone who provides a diagnosis that fits their own perceptions.

Most people also want an understandable explanation of their symptoms. When symptoms are not explained, people may assume the health professional does not believe them or perhaps that they are imagining the symptoms. Overly technical explanations, however, often confuse and frighten people.

People often experience anxiety about seeking help with health problems. Even minor symptoms can be construed as serious. Therefore, clients need reassurance that they will be cured. Even when this reassurance cannot be given, most people want to know the likely outcome.

When a health professional has validated that the person is ill, the individual becomes a client, dependent on the professional for help. During this stage, sick people may or may not be reluctant to accept a professional's recommendations. They may vacillate about what is best for them and alternately accept and reject the professional's suggestions. People vary greatly in the degree of ease with which they can give up their independence, particularly in relation to life and death. Role obligations-such as those of wage earner, father, mother, student, baseball team member, or choir member-complicate the decision to give up independence.

It is also common for the client and the health professional to hold different notions of the nature of the illness, unless complete and open communication exists. During this stage, a nurse can often provide information that may allay some fears and/or provide data that support the person. Misconceptions can result from limited information, which clients interpret in the light of their experiences. For example, a woman may be told by a physician that there is a small encapsulated growth in the right groin and that surgical removal is advised. If the woman's mother died after being told she had a growth in her breast, that person may assume that she also will die.

Most people accept their dependence on the physician, although they retain varying degrees of control over their own lives. For example, some people request precise information about their diseases, their treatment, and the cost of treatment, and they delay the decision to accept treatment until they have all this information. Others prefer that the physician proceed with treatment and do not request additional information.

During this period, sick people often become more passive and accepting. They require a predictable environment in which people are genuinely concerned about them. In addition to being concerned about themselves, some sick people regress to an earlier behavioral stage in their development. As a result, they may have fewer coping mechanisms (physical and emotional adaptive or defensive abilities). Frequently reactions are related to previous experiences and to misconceptions about what will happen.

People have varying dependence needs. For some, illness may meet dependence needs that have never been met and thus provide satisfaction. Other people have minimal dependence needs and do everything possible to return to independent functioning. A few may even try to maintain independence to the detriment of their recovery.

During this fifth stage, the client learns to give up the sick role and return to former roles and functions. For people with acute illnesses, the time as an ill person is generally short, and recovery is usually rapid. Thus, most find it relatively easy to return to their former life-styles. People who have long-term illnesses and who must make adjustments in life-style may find recovery more difficult. Recovery is particularly difficult for people who have to relearn skills such as walking or talking.

During this stage, readiness for social functioning may not coincide with physical readiness. People may be physically able to go out to dinner but find that functioning socially is still too stressful or they may find that they have the desire to perform activities but not the strength. Nurses can help clients function with increasing independence by planning with them those functions they can accomplish by themselves and those with which they need assistance, It is also important for nurses to convey an attitude of hope and to support the client's return to health.

Sick role behaviour is "the activity undertaken by those who consider themselves ill, for the purpose of getting well." Parsons describes four aspects of the sick role:

1. Clients are not held responsible for their condition.

2. Clients are excused from certain social roles and tasks.

3. Clients are obliged to try to get well as quickly as possible.

4. Clients or their families are obliged to seek competent help. Many Indians believe that illness, though undesirable, is beyond a person's control and that individuals are not responsible for incurring an illness, Some subcultures view illness as punishment from God, and therefore consider the infirm responsible for their illnesses, because of their sins, This folk belief persists to some degree in Indian society. A client may say something like, "What have I done to deserve this?" This remark reflects a sense that illness is a punishment. Today, because of the recognition that life-style contributes to illness and disease, some people-for example, the cardiac client who smokes or the overweight person who develops diabetes-are being held increasingly responsible for developing some illnesses.

Nurses can help clients by providing factual information and by not judging the client. It is important to encourage behaviors that promote health and not to reinforce behaviours that may have helped bring about an illness.

The sick person is usually excused from some normal duties. Social pressures on the sick and people's expectations of the sick usually depend on the prognosis and the severity of the illness. People who are severely ill and whose prognosis is poor or uncertain are permitted more dependence than people who are less seriously ill. People who are not seriously ill and whose prognosis is good are more likely to be encouraged to fulfill personal and social responsibilities. The person with a cold may still be expected to give a scheduled speech or to take an examination. People who are chronically ill may be permanently exempted from some duties or activities by society.

Some people may express feelings of guilt because they are unable to fulfill their normal responsibilities. Nurses can express support to clients who cannot fulfill their perceived roles and help them substitute other appropriate activities, when desirable. For example, a young father who cannot play ball with his son may be able to help his son build a model airplane, thereby fulfilling the father's role in another way.

Another aspect of the sick role is the obligation of the person to get well as quickly as possible. The sick role is a dependent one, at least in some respects. The person who fears dependence may be threatened by assuming a sick role and having to seek help. This individual might ignore advice despite the most serious consequences. Some people, however, find dependence gratifying, Some clients find dependence so satisfying that they perpetuate the sick role and do not try to get well or continue to complain of symptoms even after they are physically well. Some people in the dependent stage also find it satisfying to control others through excessive demands. With exceptions, people usually try to get well as quickly as possible.

Nurses can help clients assume a dependence appropriate to their developmental status and health. Part of the nurse's function is to reinforce both dependence and increasing independence at the appropriate times. For example, a man who is acutely ill may have to be shaved by the nurse; however, once he is stronger the nurse can assist him by providing shaving supplies and later complimenting him on his appearance.

An essential aspect of the sick role is seeking competent help. This presupposes that competent help is available to the client. It should also be recognized that the client's notion of competent help may be different from the general population's. For example, a man with a whiplash injury may become dissatisfied with his physician's treatment because of his slow recovery and may go to a healer who uses hypnotism. Or a domineering, talkative woman may reject advice to see a therapist and decide instead to join a cult of young people, considering the members of the cult competent help.

Nurses need to encourage some people to obtain competent heir from health professionals. Nurses who are aware of the health facilities available in a community can assist people to obtain care. People may require considerable support before seeking assistance because, for example, they fear the health problem might be serious or they believe competent help might not be available. A nurse's function in these instances is to provide accurate information about available health facilities while recognizing clients' beliefs and their right to hold them.

Normal patterns of behavior generally change with illness; with hospitalization, the change can be even

greater. Hospitilization usually disrupts a person's privacy, autonomy, lifestyle, rules, and finances.

When a client enters a hospital or nursing facility, the loss or privacy is instantly obvious. Privacy has been described as a comfortable feeling reflecting a deserved degree of social retreat. Its dimensions and duration are controlled by the individual seeking the privacy. It is a personal internal state that cannot be imposed from without.

People need varying degrees of privacy and establish boundaries for privacy; when these boundaries are crossed, they feel invaded. Hospital personnel sometimes show little concern for clients' privacy. Clients are asked to provide information that often they consider private; they may share a roam with strangers; and their health is frequently discussed with many health professionals.

The boundaries of privacy are highly individual. The adult who lives alone may he used to privacy while eating, sleeping, and reading. A child from a large family may be accustomed to sharing these activities with others. It is important for nurses to ascertain what privacy means to the individual and try to support accustomed practices whenever possible.

Autonomy is the state of being independent and selfdirected without outside control. People vary in their sense of autonomy; some are accustomed to functioning independently in most of their life activities, while others are more accustomed to direction from others. An example of the Basanth is a writer who lives alone and works independently. By contrast, a wife in a patriarchal home may be accustomed to having decisions made by her husband and receiving direction from him.

Hospitalized people frequently give up much of their autonomy. Decisions about meals, hygienic practices, and sleeping are frequently made for them. This loss of individuality is often difficult to accept, and the client may feel dehumanized into "just a piece of machinery." Nurses have a major responsibility to humanize care by learning about the client as a person and by individualizing nursing care plans.

Hospitalization marks a change in life style. Many hospitals determine when people wake up and when they sleep. The woman who normally rises at 8:00 a.m. and the man who usually works until 11:00 p.m. must change their habits. Food in a hospital is usually mass produced, and individual differences in taste are not always accommodated. Occasionally hospitals have relatively large populations from a particular culture and make special food arrangements. However, individual preferences are not always met.

Nurses can help clients adapt to life in a hospital in several ways:

• Providing explanations about hospital routines.
• Making arrangements wherever possible to accommodate the client's life-style, such as providing a bath in the evening rather than in the morning.
• Encouraging other health professionals to become aware of the person's life-style and to support healthy aspects of that life-style.
• Reinforcing desirable changes in practices with a view to making them a permanent part of the client's life-style.

Hospitalization often places a genuine financial burden on clients and their families. Even though many people have health insurance, it may not reimburse all costs; in addition, many lose wages while they are hospitalized. Nurses can be aware of these costs and provide care that is as economical as is safely possible; for instance, they can use only the minimum supplies necessary for safe care. In some agencies, nurses may initiate referrals to the social service department to assist clients in making arrangements to address the financial burdens imposed by hospitalization. When this is not an independent nursing function, the nurse should consult with the client's physician to obtain such a referral.

A person's illness affects not only the person who is ill but also the family or significant others. The kind of effect and its extent depend chiefly on three factors: (a)

which member of the family is ill, (b) how serious and long the illness is, and (c) what cultural and social customs that family follows.

The changes that can occur in the family include the following:

• Role changes
• Task reassignments
• Increased stress due to anxiety about the outcome of the illness for the client and conflict about unaccustomed responsibilities
• Financial problems
• Loneliness as a result of separation and pending loss
• Change in social customs.

Each member of the family is affected differently depending upon which member of the family is ill, because each plays a different role in the family and supports the family in different ways. Parents of young children, for example, have greater family responsibilities than parents of grown children.

The degree of change that family members experience is often related to their dependence on the sick person. For example, when a child is ill, there are few changes other than added responsibilities directly related to the child's illness. When the mother is ill, however, many changes are often necessary because other family members must assume her functions.

When an elderly person is ill, a son or daughter often assumes the role of parent to the elderly person, providing housing, meals, and assistance with daily needs over a prolonged time. In other words, the parent-child roles are frequently reversed. This role reversal may be only temporary and may end when the illness ends, or it may become permanent.

The whole family, particularly the spouse of the sick person, experiences stress and concern about the outcome of the illness. Usually, the sick person's spouse feels a pending loss or separation most keenly. After a marriage of 50 at 60 years, elderly people may find it difficult to envisage what life will be like without a husband or wife. Younger persons in the family may deal with serious illness in an elderly person by stating, "He has led a good life" or "She had so much pain the past years." In this way, the young prepare themselves for that person's death. This same reasoning is rarely applied to a child or younger adult who is ill.

When an elderly person is ill, adult sons and daughters may face conflicting responsibilities. A daughter who lives some distance away needs to maintain her job and look after her own family, but at the same time her parents need her in another city. How often should she visit? How should she fulfill her responsibilities? These questions pose problems for many families today who live far apart.

The financial problems of the sick elderly can be a major problem for a family as well as a community. Because illness in this age group tends to be chronic, the costs of illness are often considerable. The greatest change in life-style is that the family must now allot time for hospital visits to the elderly relative.

When the sick person is a parent, the degree to which the family experiences change is related to the responsibilities the individual has and the number and age of dependents in the person's care. For example, when a father is ill for a long time, his roles are usually taken over by other members of the family, frequently the mother. Such tasks as doing chores in the house or attending a child's basketball games, for example, are either reassigned or not performed at all. Anxiety of family members about the outcome of a parent's illness is usually high, especially if the parent is a wage earner. The implications to the family of prolonged illness or death are great in almost all areas of living because of the needs of the dependents.

Prolonged illness of the mother can have equally serious consequences. Often the children do not understand why their mother is in the hospital, and they may feel lonely and unwanted. Sometimes the mother's functions are taken over by grandparents or by aunts and uncles as well as by the father. When a young mother has a serious illness of unknown outcome, the father and family face worrisome problems of how to manage over a long period of lime. Most arrangements have financial implications and involve role changes for the father and children. In this situation, the father must become both father and mother and give up many of his normal social activities. The children may also need to assume more housekeeping functions.

Because a child is dependent on parents for so many daily needs, both sick children and their families may need to make fewer role adjustments than sick adults and their families. Task reassignments are also generally minimal. Sometimes a younger sibling takes over a paper route for a sick brother or sister, and other members of the family share the sick child's chores.

"Infection is a dynamic process involving invasion of the body by pathogenic micro-organisms and reaction of the tissues to organisms and their toxins." Contamination is mere presence of organism at any site without invasion and without features of inflammation.

Process of Nosocomial (hospital) infection results from the transmission of pathogens to a previously uninfected patient from a source in the hospital environment which is also a cross infection. The pathogens may also come form the patient himself (autoinfection). He may be a carrier of the pathogen or may become contaminated with virulent hospital strains during stay in the hospital. Nosocomial infections are iatrogenic when the source is the attending physician or surgeon and the team or measures adopted viz. frequent or prolonged use of supportive procedures such as indwelling venous or urinary catheters, tracheostomy tubes, and equipments for respiratory care. Nosocomial infection increases morbidity, mortality, stay and expense of the patient and worriers of the relatives.

A surgical infection is an infection which requires surgical treatment of surgical treatment and essentially is a wound infection.

A variety of organisms may be responsible for wound infections. Pathogenic bacteria infecting wounds are:

i. Gram-positive cocci-Streptococci, and Staphylococci. ii. Gram-positive bacilli-C. diphtheriae. iii. Gram-negative bacilli - B. pyoscyaneus, E. coli, B. proteus.

i. Gram-positive cocci - Streptococci. ii. Gram-positive bacilli - Clostridia tetani, Clostridia welchii, Clostridia botulinum, etc. C. Microaerophilic bacteria: Streptococci.

The micro-organisms commonly encountered in surgical infections are staphylococci, streptococci, clostridia, bacteroides, and the enteric bacteria.

The sources of bacteria which may come in contact with the wounds are:

1. The air and dust.
2. The nose, throat, mouth, skin of surgeon and the team.
3. The skin and other focal septic sources of the patient.
4. Materials used for toileting or dealing with the wound or in the operation field viz., instruments, swabs, threads, dressings etc. In traumatic wounds the source of infecting bacteria are patient's skin or clothing or foreign body. In surgical wound the infection begins in the operation room, the sources being poor aseptic technique (including sterilization), excessive tissue trauma, incomplete hemostasis etc.

Mode of entry: Sexual or close contact, skin to skin contact, parenneral fluid, through oral and respiratory passage etc.

Mode of Entry: The injurious effect of infection is due to the released toxins by bacteria. They may be either exo or endotoxins. Exotoxins are specific soluble diffusible proteins produced by gram-positive bacteria during the growth of organism e.g., clostridia group, Streptococci, Staphylococci, C. diptheriae, Sh. Dysenterae, Endotoxins are produced by the organisms and are kept inside the body. These are liberated after their death e.g., Salmonella typhi, E.coli, bacteroides. Most of the common pathogenic organisms produce endotoxin.

All these toxins have both toxicogenic action and property of inducing production of antibody in the

host. When these toxins are isolated and toxic property is destroyed they can be used to produce antibodies in the host after destroying their toxic property only. These are called toxoids. The effects of toxins may be local or general.

Effects: Local effects are due to (i) Increased vascularity, (ii) vascular thrombosis, (iii) Tissue oedema, (iv) Fibrinolysis, (v) Suppuration and (vi) Necrosis.

The general effects are due to bacteremia, toxaemia, septicaemia or pyaemia.

"It is the reaction which occurs in immediate response to irritation or injury usually manifested locally." The aim is to neutralize or remove the irritant.

The classical features of inflammation are redness, swelling, heat, pain, and impairment or loss of function of that part.

Fever and chills indicate septicaemia, while elevated pulse rate is a sign of a toxic state.

Leukocytosis accompanies an acute bacterial infection more often than a viral infection. The more severe the infection the greater is the leukocytosis. In most infections the total leukocyte count is only slightly or moderately elevated.

Some common surgical infections and conditions: Cellulitis is a nonsuppurative inflammation of the subcutaneous tissue.

Lymphangitis is an inflammation of lymphatic pathway. This is usually visible as erythematous streaking of the skin in fair complexion subject and is commonly seen in infection by haemolytic streptococci.

Erysipelas is an acute spreading cellulites and lymphangitis, usually caused by haemolytic streptococci which gain entrance through a break in the skin.

An abscess is a localized collection of pus surrounded by an area of inflamed tissue. A furuncle or boil is an abscess in a sweat gland or hair follicle.

Impetigo is an acute contagious skin disease characterized by the formation of intraepithelial abscesses.

A curbuncle is a multilocular suppurative condition in the subcutaneous tissues. The nape of the neck, dorsum of trunk, hands and digits are common sites. It is also called infective gangrene. This is commonly seen in diabetic persons.

Most abscesses are caused by pyogenic cocci. Commonest is Staphylococcus aureus.

Bacteremia is defined as presence of bacteria in the circulating blood.

Septicaemia is the condition in which bacteria multiply in the blood stream e.g., Salmonella, E. coli, Ps. Pycocyneus, Streptococci, Staphylococci, Proteus etc.

Pyaemia is when pyogenic micro-organisms are carried in the blood stream in the form of bacterial emboli or as infected clots to different parts of body where these initiate multiple focal abscesses.

In toxaemia toxins are circulating in the blood e.g. in Diptheria, Tetanus and Dysentery.

Asepsis can be defined as exclusion of organisms from coming in contact with the wound or operation field. It is basis of modern surgery. Louis Pasteur is called the father of aseptic surgery as he was the first to discover presence of microbes in the air and contamination by them.

1. Medical asepsis: Those practices by which spread of infection from a diseased person is prevented. All articles coming in contact with the patient are rendered free form pathogenic organisms but are not necessarily sterile.
2. Surgical asepsis: Indicates that all objects coming in contact with the patient are absolutely free from all organisms pathogenic and non-pathogenic, including sporebearers.

Sepsis: It denotes presence of infection. Antisepsis is killing of all organisms already present in the wound. J. Lister first started antiseptic measures by disinfection of sewage etc. with carbolic acid and is called the father of antiseptic surgery.

For carrying out proper asepsis and antiseptis several rituals have to be observed.

1. Designing of operation theatre: It should be airconditioned, dustless, well ventilated with planned circulation of air. Regular cleaning and disinfection

of wall. Separate septic and aseptic operation theatres and standardized operation theatre complex. 2. Movements in operation theatre: should be restricted. 3. Over crowding in operation theatre has to be avoided. 4. Nasal carriers should be detected and are not allowed to enter operation theatre. 5. Surgical team should no handle infected wound, burns or colostomy wound before going for an operation. 6. Proper cleaning (including paring of nails) or surgical team and putting on sterilized gowns, masks, caps, gloves etc. 7. Proper preparation of the patient (vide preoperative prep). 8. Sterilisation of instruments. 9. Sterilisation of drugs as and when necessary.

1. Local treatment of wound - by cleaning, debridement, excision, application of medicines in the form of powder, drugs, lotion, ointments, packs, drainage etc.
2. General-Administration of drugs viz., antibiotics, chemotherapy (bactriostatic or bactericidal) etc.

Sterilisation is killing of al sorts of micro-organisms including bacteria, viruses, spirochaete, fungi, parasites and spores.

Disinfection - is killing of all organisms except spores. Disinfectant - is a chemical substance of germicidal nature used to kill pathogenic micro-organisms of inanimate objects.

Antiseptic - is also a chemical agent but differs from disinfectant in a sense that these inhibit growth of micro-organisms so long they are in contact with them.

All pathogenic organisms can be destroyed by any of the following methods as given below:

Sunlight: The heat of sunlight have a drying or dehydrating effect on the organisms which enables it to destroy the germs. This method is not effective unless the contaminated articles are exposed for 2-3 days continuously and hence is not usually applicable.

1. Dry heat: a. Electric (hot air oven) - By special electric ovens in the form of hot air at $121^{\circ} \mathrm{C}$ for 6 hours (commercial). Materials - Glasswares, vaselin, fats, talc, oils, carbon steel materials. Linen, rubber or plastic articles are not sterilized in this method. b. Flaming - Contaminated noninflammable articles are sometimes disinfected by smearing with methyllated spirit and then flaming. This method destroys only surface bacteria and can be used in case of grave emergency or when no other way of disinfection is possible, e.g., tray, blunt instruments. c. Burning or incineration - Contaminated articles of highly infectious diseased patients are burnt to kill the micro-organisms and prevent spread of infection, e.g., mattress, pillow, bed linens used by tetanus or gas gangrene patient.
2. Moist heat: a. Boiling - This is one of the commonest method of destruction of micro-organisms. In this, bacteria are killed within 5 to 30 minutes e.g., syringe. Almost all instruments except sharp, rubber goods, silk, nylon, etc. b. Chemical method-Chemical substances, called disinfectants are also used to kill pathogenic organisms. The stronger the chemical the lesser is the time required for disinfection. Common disinfectants are Lysol, carbolic acid, formalin.

The choice and action of disinfectants depend on:

1. The type of article to be disinfected e.g. metal, rubber, or linen.

2. The nature and strength of agent used and its effect on the qualities e.g., effet of Lysol 1:20 and carbolic 1:40 and its stability in the presence of organic matter.

3. Time required for disinfection by the chemical to act effectively.

4. Nature of solvent used and its temperature.

5. Nature of contamination, the number and virulence of organisms.

6. The cost of the chemical to be used.

For practical purposes - Two common methods are there for sterilization - chemical and heating. A combination of pressure and heat is undertaken for a special advantage that pressure increases heat and power of penetration is more. The different methods are briefly tabulized.

Autoclaving - For materials that will stand up to heat and moisture. In this method with increased pressure, temperature of water can be raised. This the most reliable method because of the power of penetration, microbiologic efficiency, easy control, and economy. 15 lb pressure per sq. inch for $15-45$ minutes at $121^{\circ} \mathrm{C}$ destroys al forms of organisms.

Materials sterilized - Almost all materials except glass wares, vselin, fats, talc, oils, etc.

There are two types:

1. Those with gravity displacement of air.
2. Those with high vacuum sterilizer.

Steam with - Formaldehyde at subatmospheric pressure sterilization is done at a temperature below $90^{\circ} \mathrm{C}$ at 10 lbs pressure for 10 mts . All spores are killed when formaldehyde vapour is used. It is a modified autoclave system.

Pasteurisation - Is the method where materials are sterilized in thermostatically controlled water bath at $75-80^{\circ} \mathrm{C}$ for 10 minutes, e.g. - Endoscope.

Irradiation - Gamma ray is used for sterilization in industry - Irradiation is from a cobalt 60 source or electron bormbardment from a linear accelerator.

Mateials sterilized - viz. disposable hospital supplies, plastic, syringes, sutures-catgut, etc.

Ethylene oxide gas - for heat labile article - This is also commercial.

Materials - delicate surgical instruments with optical lenses, plastic parts of heart lung machine etc.

Chemicals - common solutions used are iodine, Lysol, carbolic acid, hibitane, cetrimide $1 \%, 2 \%$ glutaraldehyde.

1. For sterilization of living tissues catguts etc.
2. Sharp instruments in pure Lysol for half an hour, etc.

This is preparing a patient for a surgical procedure. The pre-operative period is the time during which a person is prepared for surgery. This period varies in length and depends on the patient's condition. Surgery is a traumatic event for most patients. The better the patient is prepared and instructed for surgical procedure the easier is his post-operative course and the shorter is the convalescence.

Psychological consideration: Surgery is viewed as a crisis in life. Emotional responses to surgery may be manifested in various ways. Some patients may be talkative, some withdraw and some other may show non-adoptive responses. After assessing the patient carefully, appropriate nursing intervention can be planned.

A complete assessment of health status is a part of a preparation for surgery. a. The patient's age: The young and old are less able to cope with stresses. b. Nutritional, water and electrolyte status: Surgical risk is increased when the patient is malnourished and dehydrated. c. The presence of previous pathological condition: The nurse should observe the signs of disease. d. Special conditions affecting the surgical risk: i. Obesity - The surgical risk is higher than the patient with normal weight. ii. Acute infection - An acute infection anywhere in the body requires a delay in surgery in most instances to help prevent post-operative complications. iii. Drug therapy - The drugs which have profound effect are hypoglycaemic, hypotensive, psychic, anticoagulants, steroids, etc. Continued use of anticoagulants may cause serious haemorrhage. Steroids also have serious effects on surgical patients.

iv. Addiction-Alcoholism-Withdrawal symptoms may develop when a patient suddenly is deprived of alcohol during the surgical experience. In smoking post-operative pulmonary complications are more. v. Wasting diseases - In diabetes mellitus the stress accompany the surgery may increase the need for insulin. e. Skin disease at the operative site should be treated prior to operation.

The most important part in pre-operative management is health teaching. Teaching should include sharing information about purposes of various types of care the patient receives pre-operatively and postoperatively. a. Diaphragmatic breathing. This causes deep breathing and helps the patient ventilate thoroughly. It is carried out as follows: i. The patient lies on low Fowler's position, flexing knees and placing his hands over his lower rib cage and on sides of the abdomen. ii. The patient exhales thoroughly, his ribs move downward with exhalation. iii. Then he takes deepest breath. iv. The patient holds the breath for 3-5 seconds after inhaling deeply. v. Then he exhales through pursed lips holding in a manner as though he will whistle taking double the time to inhale action. The patient is helped to practice this breathing twice a day for at least 15 times in each sitting. b. Coughing: i. The patient lies in Fowler's position or a sidelying position. ii. The patient's hands are placed on the incision area to splint the surgical wound. iii. The patient takes a deep diaphragmatic breath. iv. After inhalation the patient is asked to make two strong coughs while keeping the mouth open, tongue extended and hands in position. v. The patient then takes another deep breath and gives two more strong coughs. vi. The patient pratices coughing at least two or three times a day. c. Moving in bed: i. The patient is placed on back and is asked to flex on knee to about $45^{\circ}$ to $90^{\circ}$ and holding this position for a few seconds to extend the leg. This is done alternately. These exercise are repeated four to five times every 3-4 hours. 2. Legal considerations: i. The patient is placed must be told about the operative procedures, risk, possible complications and what disfigurement can occur. ii. He should be informed what expect during postoperative period. iii. Operative consent is to be taken from the patient, in the presence of witness. Parents or a guardian must sign for minor. 3. Psychological preparation of the patient and family: Most of the patients fear for surgery. Common fears include fear of death, unfavourable diagnosis, disablement which may bring disruption in family lift etc. There is worry about anaesthesia, loss of self control and financial and employment limitations. i. The nurse should have knowledge of the type of surgery the patient is to undergo to guide for preparing the patient both psychologically and physically. ii. The patient is to be given opportunity to discuss his fear and concern. It also includes listening to what is being said as well as nonverbal communication. Touch when used appropriately conveys the message of showing an interest in what the patient is experiencing. iii. It is important to consider each patient as an individual person. Each will respond emotionally to a surgical experience in his own way. iv. The nurse should also prepare family members for the special equipment needed in the care of the patient. She should offer emotional support to family members.

1. Regular bath with soap or cleaning after admission.

2. Maintenance of oral and general hygiene.

3. Any infective fever should be treated.

4. Bowel should move regularly.

5. Fluid intake should be plenty. When necessary glucose drinks in large amount e.g., in jaundice.

6. Adequate diet followed by light diet in evening before operation and nothing by mouth on the day of operation is the standard method unless ordered specially

7. Tranquiliser on the night before operation.

8. Infants, children are old-age require special care. Infant and children are susceptible to infection; they tolerate fluid and electrolyte imbalance badly and they may have congenital disorders. The elderly are prone to have pulmonary, cardiovascular, urinary and liver disorders which should be taken care of.

9. Pre-operative antibiotic administration to prevent risk of post-operative infection.

10. Preparation of the patient immediately preoperatively: a. Skin preparation at the site of surgery - The area of the skin prepared is larger than the immediate area around the incision to reduce the chance of infection. Where applicable the hair in the operative area is shaved. Sterile dressing may be applied to the cleaned and shaved area. b. Administration of a cleansing enema as ordered because a full colon can cause contamination during surgery. The patient may have an involuntary bowel movement if the lower intestinal tract is not emptied while he is being anaesthetized. c. Checking of the vital signs. Any abnormality of vital sign should be reported promptly. Surgery may need to be cancelled if abnormalities are present. d. Removing of patient's valuables such as rings and wrist watch. Removing of dentures, contact lenses, artificial limbs and eyes, wigs, hair pin, clips and coloured nail polish. Braiding the long hair and putting on the hospital's cloth. e. The patient should void urine before going to operation theatre. f. Administration of the pre-operative medication at the time ordered. g. Completing the patient's record. h. Helping to move the patient in stretcher after checking the patient's identity. i. Accompanying the patient to the operative room and handing over the patient and records to be operation room nurses. j. Special preparations are given as ordered for some surgical conditions viz. cardiothoracic surgery, urosurgery, etc.

This includes those patients who have

1. Malnutrition.
2. Vitamin deficiency.
3. Anaemia.
4. Hypoproteinaemia.
5. Fluid and electrolyte intake.
6. Obesity.
7. Cardiac and respiratory diseases.
8. Wasting diseases e.g., Diabetes, tuberculosis, cirrhosis of liver, rheumatic arthritis. These should be treated as far as practicable.

1. Preparation of patient's room: Recovery room should be in the same floor. The furniture should be so arranged that stretcher on which patient is transported can be moved near the patient's bed. Preparation of the operation bed is done with clean linens. All equipments that may be necessary should be available viz. oxygen, suction machine, sphygmomanometer, infusion fluids and shock blocks, airway, emergency medicines etc.
2. Maintenance of pulmonary ventilation: The patient should be in a position so that he can breath normally with full use of all portions of his lungs and that vomitus, blood and mucus can drain and will not be aspirated. They lying position on the side is preferred after the airway has been removed to facilitate drainage from mouth and nose.
3. Maintenance of circulation and prevention of shock: As soon as the nurse is certain that the patient's airway is clear, she should check the blood pressure and pulse. The blood pressure, pulse and respiration are usually taken every 15 minutes for first 2 hours, then every half hour for another 2 hours and eventually every 4 hours until further orders. The rate, volume and rhythm of the pulse should be carefully observed and character and rate of respiration noted. A rapid

thready pulse with sudden drop of blood pressure may indicate haemorr-hage or circulatory failure. The surgeon should be notified immediately. Oxygen may be given to increase its concentration in the available circulating blood 4. Protection from injury: Following anaesthesia, side rails are usually placed on the bed and are left until the patient is fully awake. Hot water bottles, heating pads or heat lamps must be used with care while the patient is unconscious. When infusions are given, the patient's arm should be secured on an arm board so that needle is not dislodged. The patient should be turned frequently and placed in good body alignment to prevent - i. Nerve damage from pressure and ii. Muscle and joint strain due to lying in the same position for a long period of time. 5. Facilitate breathing and prevent hypostatic pneumonia: Frequent changing of position. Raise the head end of the bed as soon as the systolic B.P. rises to 100 mm . of Hg. Steam inhalation every 6 hourly. 6. The nurse must check for soakage or bleeding. She should also look for tubes of any kind and connect them in drainage system as ordered. 7. Maintenance of fluid and electrolyte balance: An adult requires about 2.5 litres and as much salt as contained in 1 pint of normal saline and 70 gm . of protein in 24 hours. This salt should be maintained when I.V. infusion is given. There should be complete and accurate intake/ output charting in the post-operative period. All fluids, medications and treatments that the patient received during this time must be recorded so that there will be no duplication. 8. The nurse can ascertain the return of reflexes and consciousness of the patient by asking him his name and others. The patient may be returned to his room as soon as his blood pressure is stable, he is breathing freely, not vomiting and fully awake. 9. Retention of urine is a usual complain after perineal, rectal or hernia operation. An indwelling catheter pre-operatively introduced is safe, otherwise if conservative measures fail a self retaining cathether should be indwelled. 10. Vomiting: This may occur after general anaesthesia. In abdominal operation if Ryle's tube is there suction prevents vomiting. Otherwise if needed may be introduced later. In other operations usually vomiting tendency passes off. Anitiemetics may be necessary. 11. Oral hygiene: This is important to prevent parotitis, gingivitis, bad odour etc. 12. Diet: It is advised depending on abdominal or extra-abdominal operations. In abdominal operations only water is first allowed till flatus is passed. In other water is first allowed till flatus is passed. In other conditions fluid is allowed after some definite period. 13. Bowel: No purgative is advised in abdominal operations. Suppositories in some cases viz. appendicectomy and enema in selected cases viz., after cholecystectomy are advised after 4th or 5th day usually. In extra-abdominal operations it is usually not a problem. 14. Ambulation: Nowadays, early ambulation is advised. This helps psychological, physical and physiological improvement. 15. Wound care: Usually dressing is changed when a drain has been left or there is wound infection. Otherwise it is changed during stitch removal.

ICCU is the acronym for Intensive Coronary Care Unit. The meaning of "Intensive" is close and maximum care to selected needy patients to over-come the crisis by watching the vital signs on the monitors and managing accordingly to save a life and to prevent further complication.

The bed strength of ICCU depends on the hospital's policy. The ideal setup should be oval shaped so that all the patients can be watched from the central monitoring system. All the beds should have glass partition covered with curtains.

Brightlights should be avoided except in emergency. Attractive light, blue curtains can be used. In any case and quiet atmosphere should prevail in ICCU.

The nurse patient ratio should be $1: 1$, means one nurse for one patient. One doctor should be on duty round the clock in ICCU.

The nurses or doctors who are working in ICCU should not use outside shoes. Slippers should be provided. Masks should be used.

Each patient should have one bedside monitor which should be connected to the central monitoring system in the centre of the ICCU.

The central monitoring system should have -

1. Monitoring scope or TV screen where all patients can be monitored together.
2. Arrhythmia monitor - any type of arrhythmia can be monitored and recorded.
3. Telemetry system of monitoring is the use of battery powered ECG transmitters that do not require direct connection of the patient to the oscilloscope. Telemetry monitoring equipment is used in the ICCU as well as in the general medical surgical units for the ambulatory patients, hence the need for nurses to acquire some basic skills in rhythm interpretation.

A friendly behaviour towards the patient and their relatives is required.

1. Cardiac: a. Acute myocardial infarction. b. Congestive cardiac failure, left ventricular failure. c. Pulmonary oedema. d. Heart block. e. After cardiovascular surgery.
2. Others: a. Some post-operative patients with respiratory failure or shock of grave concern: b. Poisoning patients with respiratory failure. c. Some patients after neuro-surgical operations. d. Patients with cardiac arrest due to any cause.

The nurse who is posted in ICCU, must have some knowledge of normal cardiac rhythm and cardiac arrhythmia for proper treatment and management.

1. Functions of nurses in ICCU: a. Monitoring of cardiac activity. b. Meeting need for oxygen - By giving oxygen inhalation, keeping the airway clean, taking care of respirators, taking care of the tracheostomy tubes. c. Vital signs - Like regular checking of pulse, temperature and kidney function. d. Intake and output chart - To make sure of heart and kidney function. e. Proper medication - In time and correct dose recording on the nurses chart. f. Rest for the patient - mental and physical by ensuring calmness of the unit, comfortable bed etc. Mental rest - by medicines or injections. g. Special diet - Diet is very important - light and easily digestable diet to prevent extra burden on the heart. h. Lab. Investigations - Both general and special tests of blood, urine, stool, skiagram. i. Elimination - To keep bowel regular to avoid discomfort by giving mile laxatives etc. j. General physical care - Like backcare, mouth care, sponging etc. k. Ambulation - Doctors will instruct about the ambulation and gradual ambulation of the patient must be done.
2. Daily reporting and recording of the patients condition, medication, rhythm strip etc. must be done so that the progress or deterioration can be determined. m Proper identification of complication and treatment.
3. Care of the operative wound if there be any.

Wound may be defined as distruption or break in the continuity of epithelial tissue. It may be revealed on the surface i.e., external or may be concealed (e.g., wound of a peptic ulcer). In common practice wound means external or visible wounds caused by injury.

Commonly wound may be caused by trauma, inflammation, pressure (decubitus ulcer), diseases

(ulcerative colitis), chemicals (corrosive), extensive heat etc.

Temporary loss of functions of all or part of the organ, haemorrhage, setting up of local and general inflammatory response, death of cells (necrosis), infection.

A. Depending on cause wounds are broadly classified as follows: a. Incised - Interruption of tissue is made with sharp cutting instrument e.g., knife, blade, edges of paper. The edges of this type of wounds are straight. So they can be brought in close approximation and healing is better. All operative wounds are incised wounds. If proper care is taken before making the wound and afterwards it heals well. b. Lacerated - Usually disruption of tissue occurs by trauma with jagged irregular edged machinery, vehicle accident, teeth or claws of animal. Skin margin is irregular. Visible bleeding is less but chances of getting contamination is very high. It is difficult to suture and takes more time to heal. c. Punctured - A deep narrow wound resulting from injury by a pointed instrument. Though the external opening of the wound is very small but internal tissues at variable depth can be injured. d. Contusion - Interruption in the continuity of a tissue is caused by trauma with a blunt object or blow or fall on a blunt object. Skin is not split and bruising of the surrounding tissue occurs. Underlying structures are likely to be damaged e.g., in crush injury. e. Abrasion - In this type superficial layer of skin gets scraped off as a result of sliding, fall or friction. A raw tender area results which can get infected very easily. f. Penetrating - Wound results from bullet or a stab. As the bullet penetrates and enters deep cavities it injuries internal organs followed by bleeding and infection. There may be point of entrance and point of exit. When both of them are there they are called perforating. B. Depending on state of contamination: i. Aseptic wound, ii. Potentially infected wound, iii. Infected wounds.

a. Shock - This varies in degree according to the size and number of wounds, amount of blood loss general condition and age of the patient. b. Haemorrhage. c. Infection - Septic fever is caused by the absorption of the bacterial toxins from an infected wound and is characterized by a persistent high temperature and other local and general symptoms of acute inflammation. d. Aseptic traumatic fever - is due to absorption of ferment liberated from extravasated blood. The temperature may rise to $100^{\circ}$ to $101^{\circ} \mathrm{F}$ on the second day after injury or operation but usually subsides within 48 hours. e. Traumatic delirium - Delirium may occur in alcoholic subjects after injury or operation.

Healing means replacement of lost tissue by viable tissue. Replacement may be by repair or regeneration. Usually two types are considered: i. Healing by first intention or primary union: This occurs in clean wound where there is no loss of tissue and minimum space is there between margins, e.g., incised wound. Healing takes place with minimum granulation tissue and minimum scar. This is achieved by proper asepsis, no soiling, no tension, thorough haemostasis and proper apposition of different layers. Acute inflammation set within first 24 hours. Plasma or serum exudation occurs into the wound which gets solidified and glues the edges together. The fibrin of the solidified plasma becomes infiltrated with fibroblasts which is due course gives rise to immature fibrous tissues. Appearance of collagen fibrils occur within 4-5 days after injury. Adjacent capillaries supply fresh blood. The immature fibrous tissue becomes organized and epithelia grow from the

edges of the skin or mucus membrane migrate and cover the surface. ii. Healing by second intention or secondary healing: When, there is loss of tissue to great extent or a gap is there between edges granulation tissue develops from the side and bottom of the wound and gradually the cavity or gap is filled up. Copious discharge or pus formation may be there. This needs to be drained and healing starts after all discharges have been drained. The wound is filled scab forms and epithelium grows from margin underneath the scab. There is organization of the clot. This is followed by wound contraction by progressive fibrosis and cicatrisation of the fibrosed scar. Healing by secondary suture - Occasionally called healing by third intention. When wounds are grossly infected and primary sutures are without any effect or sutures have been applied late a secondary suture is necessary.

1. Accurate apposition under aseptic conditions and rest to the pat.
2. Aseptic wound produced by sterilized instruments, e.g. at operation.
3. Proper sterilization all materials used.
4. Aseptic and antiseptic measures for the wound and surrounding tissue specially skin.
5. Proper haemostasis.
6. Provision for exit of collection (if any) by drainage tube or sheet.
7. Dressing of the wound to prevent contact with air or clothing.
8. Application of heat to the part to improve circulation.
9. Elevation of the part to promote venous return.
10. Nutritious diet.
11. Prophylactic antibiotics.
12. Correction of any persistent general or local cause.

i. General - Old age, anaemia, hypoprotenaemia, cachexia, poor general health, wasting diseases viz. diabetis mellitus, use of steroids and anticoagulants, immuno compromised patient and patient with hepatic and renal dysfunction. ii. Local -

1. Defective operative technique.
2. Contamination of the wound, defective closure and drainage of the wound.
3. Ischaemia of the part, local malignancy, tissue tension, presence of foreign body, lack of rest.

1. Lack of knowledge regarding asepsis.
2. Infected surgeon, nurse and technician.
3. Dust and foreign materials on O.T. furniture (inadequate) carbolization.
4. Inadequate masking of nose and mouth, use of soiled clothing and shoes by operating team (improper cleaning of clothes), inappropriate scrub up.
5. Improper cleaning of skin and improper draping.
6. Long exposure and subsequent drying of skin edges and wound surface during an operation.
7. Trauma to tissue by excessive clamping and manipulation, excessive handling and testing of suture materials.
8. Prolonged hypotension during and soon after surgery due to poor tissue perfusion.

1. Breaking principles of surgical asepsis while caring a wound.
2. Lack of personal hygiene.
3. Cross infection from other patients, relatives, doctors, nurse etc.
4. Injudicious use of antibiotics.
5. Use of contaminated articles, use of same article for many patient.
6. Inappropriate care for drainage bottle etc.

A surgical wound may get infected by any of the following organisms-Staphylococcus, Streptococushaemolytic or non-haemolytic, Clostridia, Pseudomonus, E. Coli etc.

Table 1-1: Factors Affecting Wound Healing

Most common is staphylo. Aureus - which are found on the skin and live and grow in sweat and sebaceous glands. Staphylo albus - are responsible for stitch abscess. Streptococci do not cause wound infection normally. But accidental wound might get infected by haemoloytic streptococci. The most dangerous organisms which might cause wound infection are clostridia which cause gas gangrene or tetanus.

a. Local: pain and tenderness. Warmth, erythema, edema and often purulent discharge. b. General: Fever tachycardia, leucocytosis. Patient may be in a toxic state.

Certain measures if adopted in time brings down rate of wound infection to a great extent. The nurse has an important role in reducing rate of infection. A. The medical measures:

1. To improve general health by nutritious diet, vitamins.
2. To treat preoperative infection.
3. To use antibiotics. B. Nursing measures are to be adopted at three levelspreoperative, operative and post-operative.

• Preoperative measures
• To encourage patient and relatives for short hospitalization.
• To ensure that co-existant infection is treated before operation.
• Limited shaving.
• Shaving is to be done on the previous night usually.
• Repeated antiseptic cleaning.
• Prophylaxis antibiotic according to doctor's order.
• Operative measure
• Meticulous cleaning and asepsis.
• Proper carbolization of O.T. including furniture, machine, floor.
• Adequate scrub up and use of properly clean, ironed clothings and shoes.
• To ensure that no powder remains on gloves.
• Proper draping and less handling of suture material.
• Prompt assistance so that operation time is minimized
• Proper haemostasis.
• Postoperative measure
• Proper care of wound maintaining strict asepsis.
• Daily observation of the wound with or without dressing.
• Maintain personal hygiene, early ambulation, adequate fluid intake and nutritious diet.
• Hyperbaric oxygen.
• Wound drainage and debriderment.

A fluid medium is essential for normal body function. It is the most vital and at the same time the most abundant component of the human body. Life depends upon a constant source and regulation of fluid in the body. Without fluid there would be no form of life. Electrolyte balance is closely related to fluid balance. The fluid disturbance or electrolyte disturbance leads to fatality. Fluid deprivation brings about death more early than food deprivation.

The fluid is distributed in the body in three compartments that are separated by semipermeable membrane. This is roughly distributed as follows:

Intracellular fluid is within the cell and interstitial fluid surrounds all living cells and allows for diffusion of nutrients, electrolytes, water, hormones, oxygen and waste products. Intravascular fluid is within the blood vessels.

Fluid intake: The body receives water from two sources: a. Exogenous - as drinks or wish solid foods. b. Endogenous - released during the metabolic oxidation The total fluid intake per day Water intake 1300 cc Water from solid food 1000 cc

Water produce from internal metabolic oxidation Total 300 cc 2600 cc per 24 hours

Fluid loss: Daily fluid loss of an average adult taking normal amount of fluid is usually through various sources as follows:

1. Lung
2. Kidney
3. Skin
4. Bowel
5. Negligible amount along saliva and tears

2600 cc per 24 hours. The fluid loss in babies and growing children are proportionately greater than that of an adult. Kidneys of an infant do not conserve water as effectively as the kidneys of an infant do not conserve water as effectively as the kidneys of adults. In older child and adult if the body needs water the pituitary antidiuretic hormone promotes its reabsorption from the renal tubules and excessive fluid intake is eliminated through the kidneys. If large quantity of fluid is taken rapid absorption of fluid into the plasma compartment takes place. Blood volume may be temporarily

increased as well as an increase in cardiac output. There is rapid adjustment to the increased fluid.

The normal daily replacement of water equals the normal daily loss. Since daily turnover of water of a body is more than half of his extracellular fluid volume, it is essential that his fluid losses be replaced at once.

All body fluids contain chemical compounds. Chemical compounds in solution may be classified as electrolytes or non-electrolytes. An electrolyte is a substance which when dissolves in water splits into separate electrically charged particles known as ions. Positively charged ions are called cations and negatively charged ions are called anions.

They are follows:

They are important in maintenance of acid base balance and help to control body water volume. Identical electrolytes are in three fluid compartments but the concentration of the various electrolytes in each compartment varies markedly.

In general higher the concentration of the ions the more active is the solution. Some electrolytes ionize freely and provide high concentration of ions and are known as strong electrolytes. Some others maintain a reserve of neutral molecules in the solution. These are known as weak electrolytes.

In health the ratio of cations to anions in each of the body fluids and concentration of the various ions in these fluids is relatively constant. Electrolytes move more readily between interstitial and intravascular fluid than between the intracellular and interstitial fluids.

Electrolyte loss is mainly through the kidneys. Besides this, smaller amount of loss is through the skin, lungs and bowel. The kidneys selectively excrete electrolytes, retaining those needed for normal body fluid composition. Hormones influence the selective function of kidney.

A well balanced diet contains all the substances need to maintain electrolyte balance. Any excess of electrolytes ingested will be excreted by the kidneys.

Important nursing functions include:

1. Assisting the doctor in evaluating patients fluid and electrolyte status.
2. Helping in prevention of fluid and electrolyte imbalance by replacement therapy and relief of symptoms.
3. Recognition and reporting early symptoms of fluid and electrolyte imbalance.
4. To keep a fluid balance chart.

Every patient who are receiving IV fluids should have a chart of fluid intake and output. This record should be accurate. It is critically studied to determine whether there is the expected ratio between intake and output or there is excess or deficit. Any marked change in ratio should be reported to the doctor.

Fluid given by any route should be spaced throughout the twenty-four hours period. Not only does this practice help to maintain normal body fluid levels but it provides for better regulation of the electrolyte balance by the kidney and prevents the end product of metabolism and toxic materials from being excreted in concentrated form. In this way the danger of renal damage, formation of calculi and irritation of the lower urinary tract are reduced. In addition fluid spacing prevents over-loading of the circulation.

The intake record should show the type and volume of all fluids the patient has received and the route by which they are administered. The time should be noted. The output record includes urinary output, vomiting, gastric suction and drainage from any body cavity or wound. Blood loss from any part of the body should be measured carefully.

Though diaphoresis is difficult to measure yet careful note of heavy perspiration and its duration should be recorded (accurate recording of body temperature helps the doctor to determine how much fluid the patient needs). Since, fluid loss through the skin and lungs increases the temperature rises.

Daily weight record is a good indication of the onset of dehydration or of the accumulation of fluid. The patient must be weighed on the same time and each day with the same clothings.

1. Oral rehydration therapy: The best way to restore water and electrolytes to the body is to give them by mouth. Oral rehydration therapy is based on the observation that glucose given orally enhances the intestinal absorption of salt and water and is capable correction the electrolyte and water deficit. The composition of oral fluid as suggested by WHO is as follows: Sodium chloride (table salt) 3.5 g . Potassium chloride $\quad 1.5 \mathrm{~g}$. Sodium citrate $\quad 2.9 \mathrm{~g}$. Glucose (Dextrose) 20.0 g . Potable water 1 litre

Oral rehydration mixture are now free available. The contents of the packet are dissolved in one litre of drinking water and should be used within 24 hours. 2. Parenteral: If oral route is not possible then the commonest method of replacement is by intravenous infusion. In case of infant it may be given into subcutaneous tissue if venous route is not possible. Concentrated solution of glucose should always be given IV in small amounts at time and slowly because they will pull fluid from the body to dilute themselves. Normal saline solution may cause fluid to diffuse from the tissues to equalize the concentration of salt in the fluid compartments. If any of these concentrated solutions flow quickly into the vascular system pulmonary oedema can develop rapidly. The initial signs of pulmonary oedema are bounding pulse, engorged peripheral veins, hoarseness, dyspnoea, chest pain, cough, etc.

1. Glucose $5 \%$ in distilled water is often used to maintain fluid intake or to re-establish blood volume.
2. $4.3 \%$ Dextrose and $0.18 \%$ saline may be used as Dextrose-saline. It is isotonic.
3. Isotonic solution of sodium chloride ( $0.9 \%$ ) usually is given to re-establish the blood volume.
4. One-sixth molar lactate solution may be used when sodium but not chloride needs replacement.
5. Balance solution containing several electrolytes may be used. Ringer's lactate solution, Hartmann's solution. Darrows solution are examples.

Recognition of various common conditions:

1. Water depletion (dehydration): Occurs due to diminished intake, severe diarrhea, vomiting, intestinal obstruction. Features: (a) Thirst; (b) Weakness, exhaustion; (c) Low urine volume; (d) Dry wrinkled skin and mouth; (e) Vertigo; (f) Sunken eyes; (g) Mental confusion, delirium; (h) Coma
2. Water intoxication (water excess): Occurs when excessive amount of water is given orally, intravenously or by other routes. Features: (a) Drowsiness, weakness; (b) Headache; (c) Giddiness, nausea, vomiting; (d) Breathlessness; (e) Abdominal cramps; (f) Confusion; (g) Pitting oedema (late); (h) Pulmonary oedema; (i) Convulsion and coma; (j) Low serum sodium concentration.
3. Hyponatraemia (Low sodium-ion in plasma): Common causes are intestinal obstruction, severe diarrhea, dysentery, cholera, ulcerative colitis, bilious, pancreatic or intestinal fistula. Features: (a) Headache; (b) Nausea and vomiting; (c) Muscular cramp, convulsion; (d) Weakness (e) Abdominal cramps; (f) Less sweating; (g) Sunken eyes; (h) Loss of elasticity of skin; (i) Cold extremities; (j) Fall of BP.
4. Hypernatraemia (Sodium excess): When excess of normal saline or hypertonic saline has been given IV. Features: (a) Puffiness of face, weakness; (b) Accumulation of fluid in the various serous sacs and pitting oedema; (c) In infancy - increased tension in anterior fontanelle, oedema and increase in the number of urination.
5. Hypokalaemia (Postassium depletion): Observed in ulcerative colitis, intestinal fistula, when intravenous alimentation is continued for more than 72 hours, in diabetic coma treated by insulin, in prolonged saline infusion together with nasogastric aspiration. Features: (a) Lethargy, drowsiness, slurred speech (b) Anorexia; (c) Constipation; (d) Polyuria due to incontinence; (e) Muscular weakness; (f) Mental confusion; (g) Distension of the abdomen; (h) Shock; (i) Weakness of heart muscles causing circulation to slowed down which may lead to cardiac arrest.
6. Hyperkalaemia (Potassium excess) viz. in renal failure.

Features: (a) Nausea; (b) Weakness of the muscles; (c) Colic; (d) Spasticity of muscles due to overstimulation, skeletal muscle spasm; (e) Irrigular and slow heart beat due to overstimulation of cardiac muscle; (f) Sudden cardiac arrest. 7. Metabolic alkalosis (Bicarbonate excess) accompanies with electrolyte imbalance. Features: (a) Slow and shallow breathing; (b) Tetany; (c) Convulsion; (d) Confusion; (e) Coma. 8. Metabolic acidosis (bicarbonate deficit), viz. in renal failure, shock. Features: (a) Dyspnoea, tiredness, weakness; (b) Deep and periodic breathing; (c) Stupor; (d) Coma.

Fever is an abnormally high body temperature, usually accompanied by shivering, headache and in severe instances, delirium.

The normal temperature in the closed mouth lies between $36.0^{\circ} \mathrm{C}$ to $37.5^{\circ} \mathrm{C}\left(98.8-99.5^{\circ} \mathrm{F}\right)$ when the body is at rest. Skin temperature is usually lower than that of deeper structures of the body. The rectal temperature is higher by $0.3-0.6^{\circ} \mathrm{C}\left(0.6-1.2^{\circ} \mathrm{F}\right)$ and the axillary temperature is $0.5-1^{\circ} \mathrm{C}$ lower than the oral temperature.

Pyrexia or fever is an elevation of body temperature above normal.

Low pyrexia $99^{\circ} \mathrm{F}-101^{\circ} \mathrm{F}$ or $37.2^{\circ} \mathrm{C}-38.3^{\circ} \mathrm{C}$. Moderate pyrexia $101^{\circ} \mathrm{F}-103^{\circ} \mathrm{F}$ or $38.3^{\circ} \mathrm{C}-39.4^{\circ} \mathrm{C}$. High pyrexia $103^{\circ} \mathrm{F}-105^{\circ} \mathrm{F}$ or $39.4^{\circ} \mathrm{C}-40.5^{\circ} \mathrm{C}$. Hyperpyrexia $105^{\circ} \mathrm{F}-40.6^{\circ} \mathrm{F}$ and above. Fever is a disturbed condition of the body which accompanies a rise in temperature. Fever or pyrexia present when the body temperature is raised above normal. In healthy persons the body temperature remain very constant around $98.4^{\circ} \mathrm{F}\left(36.9^{\circ} \mathrm{C}\right)$ although a slight swing of $0.5^{\circ} \mathrm{F}\left(0.3^{\circ} \mathrm{C}\right)$ above or below this figure may be normal in some people.

The temperature of the body is the balance between the heat production by means of the general metabolism of various bodily functions and heat loss through skin, lungs and exertion. The heat regulating center in the brain is responsible for the constant level of the body temperature in health.

In infection, fever is one of the most constant and reliable signs. It is probably caused by the toxic products produced by the infecting organisms.

Acute diseases, particularly infections may result in a rise of temperature. Such a condition is called pyrexia. Psychological upset such as fear or anger and hot atmospheric conditions may produce slight rise of temperature. A lowered body temperature is called hypothermia. This condition is commonly seen in elderly people in the winter season and may be caused by cold, damp accommodation, poor diet, inadequate clothing and too little exercise. Newborn babies are also susceptible to hypothermia.

• Bacterial or virus infections, e.g. diseases such as typhoid fever, lobar pneumonia
• Foreign protein, e.g. inoculations with serum or vaccine
• Injury of any type and inflammation
• Sunstroke
• Cerebral haemorrhage
• Any acute infectious disease, e.g. typhoid, broncho-pneumonia, viral pneumonitis, encephalitis, tonsilitis
• Malaria
• Measles
• Severe dehydration
• Severe salt depletion
• Rheumatic heart disease
• Diarrhea
• Head injury
• Alcohol intoxication.

• Skin is hot and dry, urine scanty and highly colored and often contains albumen

• Pulse is bounding and full at first and later becomes weak and rate increased

• Respiration rate is increased in proportion to the increase in temperature and pulse

• Mouth is dry, the tongue coated and there may be nausea and vomiting

• Loss of appetite and the patient may be usually constipated

• There may be headache, irritations, restlessness and in high pyrexia, delerium and coma may occur.

• Onset of fever is sudden or gradual according to cause
• Loss of appetite, often nausea and vomiting are associated symptoms
• Headache accompanied by restlessness and delirium
• Malaise and sometimes pain all over the body
• Constipation or diarrhoea
• Photophobia
• Convulsion
• The skin is red, hot and dry
• Pulse and respiration rate is increased. In a few cases, like typhoid pulse rate is not increased
• The output of urine is decreased.

Although fever is an essential part of the defence mechanism, most doctors advise that a patient with a temperature over $38^{\circ} \mathrm{C}\left(100.4^{\circ} \mathrm{F}\right)$ should stay in bed since his respiratory and pulse rate are increased. Because headache and irritability often accompany severe systemic infection with high fever, the room should be kept quiet and glaring light dimmed. The patient should be encouraged to sleep. A warm sponge bath, back rub and a smooth bed may help to induce sleep. Bath is needed since more body waste may be excreted through increased perspiration. To prevent drying of the mucous membrane of the mouth and nose, vegetable oil may be used to lubricate the lips and nose, patient is encouraged to clean the mouth and to take generous amount of fluids.

In fever associated with infection, toxins are often excreted through kidneys, more fluid than usual is evaporated by perspiration from the skin and by rapid respiration, more fluids are needed for accelerated metabolism. Therefore, an adult patient is urged to take 2500 to 3000 ml of fluid per day. In addition to water, fluids high in calories and containing vit. C, protein, salts and potassium, if not contraindicated by the disease, should be taken by the patient because they help to supply the body's metabolic an electrolyte needs. Solid food usually are not palatable to the patient with fever, but may be given if desired. At any cost, adequate rest and additional fluid intake are inevitable for the patient with fever.

The nursing management of the patient with fever includes the following:

• Isolation: Isolation procedure is necessary only if the fever is due to some infections diseases. The fundamental aim of isolation is to prevent the spread of infection to others including nurse herself. The patient is nursed in a separate isolation cubicle. In some cases barrier nursing is implemented in a general ward selecting a corner bed near a window and separated by a screen with all precautions to prevent the spread of infection.
• Rest: In all cases of fever except in very mildest the patient is kept in bed because making a person to lie on bed is the only possible way of ensuring rest. The room should be well ventilated without draught. Proper ventilation prevents the risk of infection as well as add comfort to the patient. Temperature of the room most comfortable $\left(5^{\circ}\right.$ to $\left.19^{\circ} \mathrm{C}\right)$. Clothes should be loose garments. Position depends upon the nature of illness. If the lungs are likely to be affected upright position and if the heart is likely to be involved semirecumbent position is used. The urgency of further rest depends on the cause of the fever. Any special reason for adoption of specific position and the wishes and comfort of the patient should be considered and the congestion of the lungs by the sameness of position should be prevented.

Rest both physical and mental is essential for the patients. So quietness with minimum disturbances is provided. Frequent disturbing of patients for doing nursing procedures and other various medications are disturbing and preventing rest to patient. As these are all essential for the cure of disease, it should be carried out in proper times but the maximum amount of rest and quietness should be provided and especially during sleep.

• Sleep: Sleeplessness or insomnia is frequently present in fever or illness. Anxiety or worry about his illness, stay in the somewhat frightening surroundings of the hospital, or many other such feelings will be the cause for insomnia. Every word or actions of the nurse or doctor near the patient will be observed suspiciously. So a cheerful countenance, sympathy and reassurance of the nurse may allay the anxiety and ensure mental rest and sleep.

Nursing measures to induce sleep such as wiping the perspiration, changing the dress, straightening the bed linen, offering bedpan or urinal, providing additional blankets, giving the drinks at bed time, shading the bright light, meeting spiritual need, carrying out the treatment before sleep, using comfort devices, proper ventilation, avoiding draughts, relieving pain if any, solving problems before night, reducing fever by nursing measures, etc. should be adopted.

In addition to the above measures to relieve the physical causes of insomnia, symptoms such as cough and dyspnea in respiratory and circulatory diseases, indigestion, constipation or hunger pains in gastrointestinal diseases, pruritus in jaundice or skin disease may all interfere with sleep. These symptoms may be relieved by specific measure. Or, sedatives may be ordered for simple reasons of insomnia after trying the nursing measures.

• Diet: A suitable diet in fever is most important because such patient will have little or no appetite and yet adequate nourishment should be given to supply the bodily needs and to replace the wear and tear and to compensate the fluid loss through sweating. In the first few days of fever, fluids or semisolid foods, at least 4 to 5 pints of fluid should be given daily such as fruit juices, weak tea, cocoa, etc. milk is the most valuable food and easily assimilated. Pure milk, Custards, Bournvita, Horlicks, Ovaltines, etc. with or without milk are suitable. If pure milk is difficult to digest, citrated milk ( 60 mg of sodium citrate to each ounce of milk) is useful. Carbohydrate in the form of glucose, ordinary cane sugar, syrup, honey or as chocolate is of particular value in fever as it supply energy and easily digested.

As soon as possible, after acute stage, the patient should be given egg, fish, meat and fruits in palatable form to maintain adequate nutrition. Particularly in long-term illness, proteins should not be withheld for long, as they are essential to replace the wear and tear.

The type of food needed to fever patients is important. So also, a suitable type of food, even should be served as frequent small feeds. Otherwise overloading digestion may give rise to flatulence, epigastric pain and abdominal distension, producing respiratory and cardiac embarrassment and such abdominal distension, will interfere with his rest and sleep. The patients own appetite is a good guide to the amount of food required.

Also, the food should be served in an attractive manner to help the patient to increase the appetite, not to waste the food and to take and digest sufficient nourishment. In fever caused by certain particular illness, specific diets are essential with special items.

• Skin and pressure areas: In case of high fever, usually there is severe sweating which needs frequent change of clothes. As sweating is very distressing and produce insomnia, tepid sponging with water at a temperature of $70^{\circ}$ to $80^{\circ} \mathrm{F}\left(21^{\circ}\right.$ to $\left.27^{\circ}\right)$ is good and conductive to sleep and help to reduce temperature.

Particular attention to the pressure areas of patients with prolonged confinement to bed especially with elderly people and frequent change of position is important because they are prone to develop pressure sores. Avoiding creases in bed-sheet and providing comfortable mattress are essential details. Rubber mattress is very useful. The presence of any paralysis or incontinence calls for extra-attention to prevent developing pressure sores.

• Attention to the mouth: With fever of any degree, the mouth is usually dry and liable to become infected resulting stomatitis. So careful routine cleansing of the mouth is done at specific times during day and swabbing with suitable solutions is best. But swabbing should be done gently as too vigorous swabbing will only do more damage. Suitable solutions for cleansing the mouth are soda bicarbonate, dilute lemon juice or glycothymoline. Adequate administration of fluid is one essential way of ensuring a clean mouth. Juices or citrus fruits will increase the salivary secretions and keep the mouth clean and prevent drying of mucous membranes of the mouth.

• Incontinence: In long-term illness especially in elderly people, incontinence of urine an stool needs special attention to prevent the development of pressure sores. Again, incontinence may be caused by an overflow resulting from retention of urine. So a distended bladder should be watched for and catheterization with strict aseptic precaution should be done if the nursing measures fail to make the patient void. In persistent incontinence, a retention catheter may be provided with drainage bottle or with frequent releasing of the same.

• Constipation: Constipation is a constant feature in acute feverish illness. It will cause distension and discomfort to the patient. It must be treated and prevented. Purgatives like senokot and cascera or glycerine suppositories or an enema may be ordered according to the condition of the patient. If a patient is on fluid diet, bowel is not be opened daily and excessive purgation will be distressing to fever patients. Some patients are prone to constipation and used to regular purgatives. The nurse must ascertain form the patient the name of the usual purgative he takes and it should be given in consultation with the doctor.

• Prevention of venous thrombosis: In patients with prolonged confinement to bed, thrombosis in the deep veins of the legs and pelvis is a danger due to sluggish circulations and trauma. In deep venous thrombosis a clot may break off, travel to the lungs, and cause pulmonary embolism which is fatal. So the limbs are moved actively and passively at intervals to prevent thrombosis and embolism and to prevent the joints becoming fixed with prolonged recombency especially in elderly people.

• Rigors: A rigor in the course of an illness is most frightening to the patient. So reassurance is important. The patient should be kept warm and adequately covered. Additional warmth may be given by the careful application of hot water bottle before sweating starts. When perspiring, tepid sponging will be necessary. Special nursing care of patient with rigor should be implemented.

• Delirium: Constant and skilled attention is necessary in all delirious patients. These patients are extremely restless and often try to get out of bed which may have serious effect. The nurse must try to restrain him with minimum force and extreme tact. In febrile delirium, cold compress to the forehead is often useful and soothing. Bed boards suitably padded to prevent injury may be needed. In most cases sedatives such as chloral hydrate, paraldehyde, compose or barbiturates may be ordered. In severe cases hyocine or morphine by inspection may be given.

In all cases of delirium, utmost skill of the nurse is required to ensure the adequate fluid intake of the patients. Elderly patients who are liable to become delirious when seriously ill require special care in the matter of fluid intakes. But delirium developed due to high fever is relieved when the fever is reduced. So measures to reduce the fever should be resorted in such occasions.

• Administering of antipyretic drugs: Antipyretic drugs such as salicylates in the form of aspirin, crossin, etc. are given to patients with fever to reduce the temperature owing to their action on heat regulating center. They relieve pain in the muscles and joints. But in strong concentrated form it is irritating to the mucous membrane of the stomach.

Whatever is the antipyretic drugs ordered, it should be given properly and the nurse should know the dose, effects and toxic reaction of the same when it is administered. Most of the drugs have good and bad effects. These should be realized by the nurse and nursing action should be directed accordingly. Salicylates in different names with different trademarks are used as antipyretics for the patient with fever. Different types of cold applications are also useful in reducing fever.

To sum up nursing measures of patient with pyrexia includes the following:

• A patient with high temperature should be kept in bed as long as fever persists. He may be permitted to get up to toilet only

• The room should be quiet and well ventilated, bright light should be avoided and the temperature is best kept between 60 and $65^{\circ} \mathrm{F}$

• An infant or young child should be placed in railed cot

• Clothing should be light and loose

• The attendants must wash their hands in an antiseptic solution before and after nursing care of the patient

• Careful observation and nursing measure should be taken to relieve discomfort. The mouth and tongue should be cleansed with sodium bicarbonate and glycerin before and after each meal. Frequent cold bath may be needed as body wastes are excreted through increased perspiration

• To prevent drying of the mucous membranes of the mouth and nose, glycerin should be applied to lubricate anterior nasal passage and lips

• Back care with methylated spirit and powder and special attention for pressure points

• Four hourly temperature, pulse and respiration should be taken and recorded on the chart

• If constipation is troublesome, the bowel should be moved by simple enema or mild laxative if there is no contraindication. If urine becomes concentrated or less than 100 ml . Daily in an adult, plenty of fluids by mouth is to be given

• Hyperpyrexia is best treated by cold and tepid sponging, cold compress to the forehead, ice cap on the head or ice packing on the body when needed. Sometimes ice-cold rectal saline is also used as retention enema to reduce body temperature NB hypothermia is now used widely for variety of illness when extremely high temperature occurs. Precaution should be taken for sudden lowering of temperature which may lead to shock. Hypothermia decreases the body's metabolic needs, lowers body temperature and inhibits growth of infection.

• A suitable diet in acute febrile condition is most important. Patient is seriously ill and inclined to take little food or has no appetite at all but adequate nourishment must be given to maintain the nutrition. In addition, owing to the excessive loss of fluid through the skin by evaporation and due to rapid respiration more fluid are needed for maintaining the metabolic processes. The adult therefore is usually urged to take 2500 to 3000 ml of fluid a day. Infant and children should be given smaller amount. In addition to water fluids with some caloric values and containing vit. C, protein, salt and potassium is preferred. If not contraindicated by the disease fluid should be taken by the disease fluid should be taken by the patient because they help to supply the body's metabolic and electrolyte needs. Solid food usually is not palatable to the patient with a fever but may be allowed if desired. The main diet is milk, but if there is any abdominal distention it is better to give skimmed milk or diluted milk. Water and sweetened fruit juice may be given freely. In addition to fluid and milk, carbohydrate is given to supply energy for the body in the form of glucose, honey, syrup or chocolate. As soon as possible further addition of semisolid diet must be made such as chicken broth, custard, cornflower, half boiled egg, soji, bread, etc. Solid food should not be added until the temperature has returned to normal.

Treatment of fever includes the following:

• Antipyretic drugs may be given for lowering the temperature orally or IM or rectally, e.g. aspirin, Paracetamol
• Antihistaminic drugs sometimes give relief to symptoms of "Cold" which is usually accompanied by fever
• Hypnotics and tranquilizers may be required to prevent restlessness or convulsion
• If nausea and vomiting accompany a generalized infection, food and fluid should be withheld for the time. Antemetics are often useful in relieving nausea. If fever is high and vomiting is frequent fluid may be given parenterally. Infants need fluid replacement much sooner than adults. Tea, broth and soda, biscuits and dry toast are usually retained best as nausea subsides
• Other specific drugs are used according to cause. After the episode of high fever the patient usually should stay in bed until the temperature has been normal for twenty-four hours. After a high and prolonged fever most adults feel weak, perspire on physical exertion and become tired easily for several days and weak. The patient of any age should have extra rest and should eat food rich in protein and high in calories. Children and young adults usually recover much more rapidly than elderly persons. During recovery the patient of any age needs quiet recreational activities such as reading to help pass the time and visitors.

Conscious means aware of an responding to ones surroundings consciousness refer to the state of being conscious. The fact of awareness by the mind of itself and the world. The words related to consciousness are as follows:

• Normal consciousness is an awareness of the self and the environment

• Sleep is a state of physical and apparent mental inactivity from which the patient can be aroused to normal consciousness.

• Clouding of consciousness is a state of reduced awareness, inattention, and sensory perception and difficulty in following detachment. There is impaired spoken words

• Delirium is characterized by irrelevant talks, disorientation, fear, irritability and misperception of stimuli

• Stupor is the state of minimal mental and physical activity, the response to spoken words is either absent or slow. The patient responds inadequately only by vigorous and repeated stimuli

• Coma is a state of total unresponsiveness. There is complete absence of response to the external environment, needs and even to repeated nervous stimuli

• Unconsciousness is an abnormal state resulting from disturbance of sensory perception to the extent that the patient is not aware of what is happening around him. It may be momentary or prolonged to days or even months. Clinically the patient who does not respond to the spoken word is unconscious. But the degree varies.

The comatose condition of the patient can be distinguished from lighter states of impaired consciousness or the semicomatose state, in that, in the latter the patient makes some response to spoken word. There are many degrees of coma. i. Light coma: This is spontaneous and evoked movement. ii. Deep coma: The heart rate is slow. But the respiratory rate is fast and the depth increased. iii. Premoribund: The rhythm is periodic. There is tracheal tug. Pulse is irregular. Blood pressure is rising. iv. Moribund: Apnoeic respiration, pupils dilated and fixed, pulse fast, blood pressure falling. The degree of unconsciousness or level of unconsciousness includes: i. Excitatory type: Patient does not respond to but disturbed by sensory stimuli, i.e. bright light, noise and sudden movement. ii. Somnolent: Patient is extremely drowsy and will respond only if spoken to directly. iii. Stuporous: Responds only to painful stimuli, i.e. pricking or pinching. iv. Deep coma: Does not respond to any type of stimulus and his reflexes are gone. Management of unconsciousness is a lack of awareness of one's environment and the inability to respond to external stimuli. Therefore, observation of the patients condition and care to prevent any complications are particularly important. If possible a nurse should be assigned "special" to the patient or alternatively he could be nursed to intensive care ward.

Common causes of unconsciousness includes the following: i. Infective: (i) Meningitis (ii) Cerebral abscess (from middle ear infection). ii. Traumatic: (i) Head injury (ii) Operation on the brain. iii. Neoplastic: Innocent or malignant growth of brain. iv. Metabolic: (i) Uraemia (ii) Diabetic coma (iii) Insulin coma (iv) Overdose of certain drugs. v. Degenerative: Cerebral arteriosclerosis causing - Thrombosis, haemorrhage or hypertensive encephalopathy. vi. Poisoning: (i) By anaesthesia (ii) Snake bite (iii) Drugs - Opium poisoning, alcohol poisoning, Barbiturate poisoning. vii. Cerebral anemia: (i) Due to shock (ii) Due to haemorrhage (iii) Due to embolus (including air and fat embolus). viii. Anaphylactic shock ix. Hypopituitarism x. Stokes-Adams syndrome xi. Cholemia xii. Eclampsia

The common causes of unconsciousness (in children) includes the following: i. Purulent meningitis ii. TB meningitis iii. Head injury iv. Hyperpyrexia v. Foreign body in respiratory tract vi. Cerebral hemorrhage vii. Intracranial tumor

1. Aim: The primary objective is preservation and prolongation of life. Treatment of airway obstruction, shock, or cardiorespiratory failure should be started before going into details of the cause of these disorders. a. Maintenance of airway:

2. Signs and airway obstruction: Stridor, respiration with effort, wheezing or cyanosis. A finger is to be swept deep into the oropharynx to remove clotted blood, mucus, vomitus, any loose teeth or dentures or any foreign body.

3. The patient is kept in semiprone position and should not lie or be restrained flat on his back in spread-eagle fashion. Spinal injury requires special consideration: a. To maintain normal body function b. To prevent complications

Generally nursing management of unconscious includes the following:

• Positioning of the patient: The patient is nursed in the prone, lateral or Sim's position. An unconscious patient is not nursed on his back because there is a risk that he may inhale vomitus or secretions from his mouth and pharynx.
• Airway: An adequate airway must be maintained at all times. It may be necessary to hold the patients jaw forward.

Garments must be loose to allow free movements of the chest and abdomen. Frequent suction is sometimes required to prevent the pooling of secretions in the patients pharynx. Sufficient ventilation should be provided.

• Observation and charting: A chart may be kept to note the patients level of consciousness, reaction to vocal stimulation, the size of pupils and their reaction to light. These observations if required, may be taken every half-hour or hour.

Temperature, pulse and respiration may be recorded every two or four hours and sometimes more frequently, particularly when the patient has a head injury.

A blood pressure chart is usually kept, the frequency depending upon the cause of unconsciousness.

The occurrence of muscular spasms is recorded. The nurse should note the area affected and the duration of the fits.

A urine analysis chart will be commenced for patients suffering from diabetes mellitus or renal failure.

A mosquito net, provided the mesh is fine enough to observe the patients colour, is used to protect the patient from flies and mosquitoes.

Sponging is performed as frequently as necessary. Tepid sponging may be required if the patient becomes febrile. When sponging the patient and giving pressure care, the limbs should be put through a full range of movements (passive physiotherapy). Passive physiotherapy for patients who remain unconscious for a long period helps to prevent stiffening of joints, muscular contractions and venous stasis.

Mouth toilets are performed to prevent drying of the mucous membrane and formation of sordes.

Eye toilets may be necessary to keep the lid margins free form discharge. The eyes must be kept closed to prevent drying of the conjunctiva and corneal ulceration.

The doctor may order the instillation of sterile oily eye drops.

The patient should, if possible, be nursed on a ripple mattress.

The bed linen must be kept taut and dry. A bed cradle may be used to take the weight of the bedclothes.

Pillows protected by plastic covers may be used to separate the bony prominences between the knees and ankles.

The patients position should be changed every hour and pressure areas massaged every two hours. Any sign of reddening or injury to the skin must be reported and the treatment intensified.

Foot drop occurring during hospitalization can be prevented by careful nursing. The feet should be kept at right ankles to the legs. Foot drop is liable to occur if the bedclothes are tucked in, tightly, causing constant pressure over the toes and feet.

A foot board or pillow at the bottom of the bed may be used to prevent the pressure and weight of clothes on the feet.

Passive physiotherapy will help to keep the ankles and feet in good condition. Padded splints may be used to maintain the correct position. If splints are used they must be removed for pressure area, sponging and physiotherapy and then carefully replaced. The hands and wrists may also need splinting to prevent wrist drop.

• Nutrition: The diet must certain adequate supply of all the nutrients required for life. These may be supplied as intravenous fluids or gastric tube feedings. If gastric tube feedings are commenced, care is taken that a variety of fluids are given, e.g. high protein milk, drinks, fruit juices and also water. The patient must be well nourished and hydrated.
• Elimination: The patient is observed for any signs of urinary retention and constipation. Any signs or symptoms of either condition will be reported, e.g. the abdomen may be distended if there is urinary retention and frequently the patient becomes very restless.

If the patient is constipated, a glycerine suppository may be ordered. However, a patient having a fluid diet will have very little faecal residue.

Incontinence of urine may occur in which case a bedpan or divided mattress may be used for a female patient and for a male patient a padded urinal or other suitable appliances may be used. These must be inspected at least every two hours.

If the patient has retention of urine, gentle pressure over the bladder region will be helpful in partially emptying the bladder. However, catheterization is generally necessary.

Accurate recordings must be on the patients fluid balance chart and the patient must be closely observed.

• Relatives: The relatives and friends must be given special consideration as they may be distressed at the patients condition. The ward sister usually arranges an appointment for them with the medical officer so that they may be informed of the patients progress. The nurse may assist the relatives as follows:

1. Check the room and remove any unnecessary equipment before the visitors arrive.
2. Explain to the visitors any new piece of equipment there may be to prevent undue alarm.
3. Arrange for a member or the clergy to visit the patient, if the relatives request this.

1. Maintenance of an adequate airway: a. The unconscious patient must be nursed on one side - semiprone position to avoid any tendency of the tongue to fallback on the throat and to encourage secretions from the mouth, respiratory tract and oesophagus to drain outward by gravity. Extension of the head and elevation of the jaw will raise the tongue out of the posterior oropharynx. b. If the patient is lightly comatose an indwelling airway tube may stimulate vomiting or an endotracheal tube may produce coughing. But in deeply comatose patient, a rubber or metal airway should remain in the mouth until the cough reflex returns. If this is insufficient an endotracheal tube should be inserted, or positive pressure ventilation should be started where applicable. c. Cleansing the air passage with an electric sucker or gauze piece. d. Patient is to be kept in steam tent to make the secretions less which should be cleaned off and on. e. Tracheotomy may have to be done to provide an adequate airway (assisting doctor if needed). Proper care of tracheotomy tube and of the wound has to be taken as a routine. If there is cardiac arrest mouth-to-mouth ventilation and closed chest massage should be started immediately. Ventilation with an oral airway and a mask, if available is very effective.
2. Control of hemorrhage: From the scalp or other parts of the body is the next most important step. This can usually be done by a suitable piece of gauze placed over the wound and secured by firm bandage. This should immediately be followed up by examination of the rest of the body for injury and management.

a. Circulation of blood is enhanced by muscle movement. The patient must not be left in a position that hampers circulation to any part of the body. b. Position is to be changed every 2 hours. c. Reddened area should be massaged gently. d. Air pressure mattress is helpful in preventing the development of decubitus ulcer. 4. Moving and position: a. Turning sheet should be used in moving an unconscious patient. b. To prevent foot drop-the foot is to be kept straightened in position against foot blocks. c. Both hands are to be kept in position, the fingers are to be rested on the pillow.

d. The wrist is to be supported on the pillow to prevent wrist drop. e. If the patient does not move, all extremities should be put through the complete range of joint motion at least twice every day. f. Massage of extremities is essential to promote circulation and to prevent venous thrombosis. 5. Anticonvulsants: During comatose condition a single convulsion may endanger patient's life. A nonhypnotic anticonvulsant like diphenyl hydration is useful. 6. Antibiotics: Are necessary depending on infectious condition, injury, etc. Any suitable one should immediately be started with.

Complications arise from loss of sensation, from paralysis and from general lowering of metabolic activity. For these reasons during nursing management a close watch is to be kept on the above mentioned points. Observation should be every 15 minutes at first till condition shows signs of improvement. a. The unconsciousness patient is placed in a clean railed cot. b. The patient is kept in flat position, at first head turned to one side and neck is to be extended for better salivation and oxygenation. c. Oxygen inhalation should be started immediately. d. Pulse rate respiration rate and body temperature should be noted carefully. e. A call book is to be send immediately to the house physician concerned indicating name, bed no., age, sex, time of admission, pulse, respiration, temperature, state of the patient and if possible the cause. Whether patient has passed urine and stool or has vomited, etc. and any treatment received outside or not should be noted. f. After sending call book emergency tray is to be kept nearby which includes: i. Physical examination set ii. Sterile Ryle's tube with syringe and specimen tube. iii. Catheterization set iv. Infusion set v. Lumbar puncture set vi. Tracheostomy set vii. Sucker machine with sterile catheter viii. Injection tray with emergency drugs g. If temperature is high - ice cap is to be applied over the head. If subnormal - patient is to be kept warm wrapped with blanket. h. Close observation and individual nursing care is essential for such patient. i. Assisting doctor during physical examination and treatment, e.g. lumbar puncture or gastric lavage or during catheterization.

a. Thorough bath with warm water is to be given daily. b. The skin should be dried properly to stimulate circulation. c. If the skin is too dry - lanolin or cold cream to lubricate. d. Proper hair wash is to be given once in a week.

a. Proper mouth care is to be given at every two hours interval. b. Artificial dentures should be removed and safely stored until the patient is fully conscious. c. Mouth gag is to be used during mouth care. d. Glycerine is to be applied over the tongue and lips because it has hygroscopic action. e. Painting of gum with $2 \%$ Mercurochrome.

a. Eyes should be carefully inspected several times a day. b. If corneal reflex is absent or if the lids are not completely closed they should be covered with an eye shield. c. Sterile paraffin or 0.5 to $1 \%$ methyl solution should be dropped in each eye to protect the cornea from drying up by providing moisture and lubrication. Negligency may cause drying of the cornea followed by ulceration which may lead to blindness.

Nutrition is not a serious matter unless the state of unconsciousness lasts for more than three or four days. Metabolic activity is depressed in these patients and caloric requirement is therefore very low. On the other hand loss of consciousness may be associated with injury or other disorders which may themselves

require administration of glucose, electrolytes, water, plasma or even blood. a. Protein and carbohydrate should be administered by IV infusion but not fat. b. To maintain all his nutritional needs nasogastric tube is used an small amount of liquid containing all essential foods are usually given 100 to 200 cc , 2-3 hourly. c. Electric sucker is to be kept ready before feeding as there is chance of aspiration. d. Before starting feeding, one should be sure that the tube is in position. e. Before and after feeding water should be given gently. Medicine may also be given slowly through the Ryle's tube. f. Proper intake and output chart must be maintained.

a. If heat regulating center (Hypothalamus) is disturbed patients temperature will suddenly rise. b. Elevation of temperature is a sign of complication, i.e. pneumonia, wound infection, dehydration, uremia, etc. c. If temperature is $38.4^{\circ} \mathrm{C}\left(101^{\circ} \mathrm{F}\right)$ bedclothes should be removed and antipyretics as advised should be given through tube or by injection. d. Tepid sponge may be given according to doctors order. e. If temperature is due to increased intracranial pressure lumbar puncture is also done several times.

The unconscious patient may have a temperature that is too low (due to depressed vital center). a. This type of patient needs extra cover b. Room heater may be used for such patient.

The unconscious patient often has both urinary and faecal incontinence. a. Regarding bladder: Foley's type of catheter should be introduced and left indwelled to control urinary incontinence, to prevent bed soiling and to keep intake-output chart. Proper aseptic technique has to be maintained to prevent complications. Continuous drainage is to be given. Proper care of the tube is to be taken.

Bladder wash with acriffin solution 1: 10,000 with proper aseptic care. Urine has to be examined for sugar, acetone and albumin at every four interval when indicated. Report is to be given to doctor and to treat accordingly. Proper output is to be maintained. b. Regarding bowel: (i) The unconscious patient usually is given an enema two or three days interval to help to prevent faecal incontinence.

If nasogastric tube is present mild laxative such as milk of magnesia may be given. c. Care of vaginal discharge: If patient has vaginal discharge it should be reported to the doctor. Sometimes cleansing douche is ordered.

The patient who is menstruating will need private care every four hours.

a. Precautions are to be taken to prevent accidents. b. No external heat is to be used, e.g. hot water bag. c. Padded side rails should be kept on both sides since patient might have convulsions. d. The unconscious patient should be observed half hourly. If condition is critical he needs observation at every 15 min interval. e. Paraldehyde 5 cc or sodium phenobarbitone 30 to 60 mg may be ordered. After sedation observation is essential for signs of depression of vital function. f. Patient should not be kept isolated in a room.

a. Pupillary reaction b. Level of consciousness c. Stiffness of neck d. Condition of limb-flaccidity, etc. e. Convulsion etc.

These will help doctor for proper diagnosis and treatment.

A rising blood pressure with slowing of pulse rate indicates increased intracranial pressure and it should be reported immediately.

Any marked change of pulse, respiration or any increase or decrease of level of consciousness should be reported immediately.

a. Patient may completely recover after being unconscious for several weeks.

b. Effort should not be made to arouse him until the level of consciousness has lightened. c. During convalescence - definite rest periods should be planned each day. d. Patient needs encouragement and security of knowing that family and friends are concern and interested in his/her recovery. e. Observation should be made for development of any complication which should properly be dealt with. Patient will also need to be reoriented since the memory is usually failing for the time immediately before, during and after the period of unconsciousness.

Pain is a complex, multidimensional phenomenon. Everyone has experienced some types or degrees of pain. Pain prompts people to seek health care more often than any other problem. Pain is one of the most common problems being faced by nurses when they are dealing with the patients. And also nurses are in an excellent position to work with the client in pain and to help the client overcome the pain. For which nurse has to gain more knowledge about pain and its management. The nurse has a responsibility to understand the experience of pain and to initiate measures that provide relief or help the client learn to cope. Because, the nurse spends more time with the patient in pain than any other health care professionals and has the opportunity to help relieve pain and its harmful effects. Some of the definitions enhance the nurse's ability to assess the client who is in pain by focusing on specific aspects of the pain experience.

1. Pain is defined by McCaffery as "whatever the person experiencing the pain says it is, existing whenever the person says it does". It is subjective experience with no objective measurement.
2. The International Association for the Study of Pain (IASP) defined, "pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or it is described in terms of such damage". Pain can be a major factor inhibiting the ability and willingness to recover from illness.
3. Mount Castle defined pain as "that sensory experiences evoked by stimuli that injure or threaten to destroy tissue, defined introspectively by every man as that which hurts".
4. Sternbach defined pain as "(i) an abstract concept which refers to a personal, private sensation of hurt; (ii) a harmful stimulus that signals current or impending tissue damage; and (iii) a pattern of responses to protect the organism from harm". The nursing definition of pain is "whatever bodily hurt, he says it does". The cardinal rule in the care of patients with pain is that all pain is real, even if its cause is unknown.

As stated earlier pain is whatever the experiencing person says it is and existing whenever the person says or does. This statement/definition makes the client the expert about his or her own pain. Because clinical pain is subjective and no objective measures of it exists, the only people who can accurately define their own pain are experiencing that pain. Although it is subjective in nature, the nurse charged with accurately assessing and helping to relieve the client's pain. To help a client gain relief, that nurse must believe that the pain exists.

Pain is a protective physiological mechanism. A person with a sprained ankle avoids bearing full weight on the foot to prevent further injury. Pain is a warning that tissue damage has occurred. The client who is unable to feel sensation, such as one with spinal cord tumor, is unaware of pain inducing injuries. Pain is a leading cause of disability. As the average lifespan increase more people have chronic diseases in which pain is a common symptom. Additional medical advances have resulted in diagnostic and therapeutic measures that are uncomfortable. Nurses care daily for clients in pain.

Pain serves as a protective mechanism. If a person touches a hot stove, the pain signal causes the person to pull the hand away immediately. The skin would be seriously burned if this did not happen.

Pain can be a diagnostic tool. The quality and duration of the pain give important dues in determining a client's medical diagnosis. For example,

in acute appendicitis, the clinician looks for rebound tenderness (the pain increases when pressure is released) when palpating the abdomen. This particular type of pain helps confirm the diagnosis of appendicitis rather than other gastrointestinal disorders.

The opioid system and the nonopioid system are the two known endogenous (developing within) analgesia systems in humans. The best known is the opioid system. It is mediated by endorphins (endogenous opiate-like substances). The nonopioid system is mediated by monoamine substances such as norepinephrine and serotonin.

When pain occurs, sensory input from injured tissue causes peripheral nociceptors (receptive neurons for painful sensations) and central nervous system (CNS) pain pathways to enhance future responses to pain stimuli. Long-lasting changes in cells within the spinal cord afferent (ascending) and efferent (descending) pain pathways may thus occur after a brief noxious stimulus.

Physiological responses (such as elevated blood pressure, respiratory rate, and pulse rate; dilated pupils; perspiration; and pallor) to even a brief acute pain episode will show adaptation within minutes to a few hours. The body cannot sustain the extreme stress response physiologically for more than short periods. The body conserves its resources by physiological adaptation: a return to normal or near normal blood pressure, respiratory rate, and pulse rate; pupil size; and dry skin with little evidence of poor perfusion, even with continuing pain of the same intensity.

Situation: The situation associated with the pain influence the person's response to it. A person's responses to pain experienced in a formal crowded situations may differ greatly from the responses were he or she alone or in a hospital.

Culture: Culture influences how people learn to react to expressing pain. People respond to pain in different ways. The nurse must never assume to know how clients will respond. However, an understanding of cultural background, socioeconomic status, and personal attitudes help the nurse more accurately assess pain and its meaning for clients. A young girl in a stoic culture may be allowed to cry because of pain whereas boys are not allowed to cry in some cultures.

Age: Age is an important variable that influences pain, particularly in children and older adults. Age may release a client from culturally imposed norms in relation to pain expression. Developmental differences found among these age groups can influence how children and older react to the pain experience. Young children have difficulty in understanding pain and the procedures nurses administer that may cause pain. Young children who have not developed vocabularies also have difficulty verbally describing an expressing pain to parents/caregivers. Cognitively toddlers are unable to recall explanations about pain or associate pain as experiences that can occur in various situation. Older people may assign different meanings to that pain. Pain is often thought by the elderly as natural manifestation of aging.

Sex: Gender may be an important influence in pain. In most cultures boys are expected to show less expression of pain than girls. As they grow older men are also expected to express less pain than women.

Meaning of pain: The meaning of a person's pain is a factor that influences his or her responses to pain. A person will perceive pain differently, if it suggests a threat, loss, punishment, or challenges. For example, a woman in labor perceives pain differently from women expressing pain from a recent back injury or pain caused by childbirth may be responded differently from pain caused by surgery. If the cause is unknown, more negative psychological factors use such as fear, anxiety, etc. come into play and the pain may be misinterpreted resulting in an inappropriate response. A client copes differently with pain, depending on its meaning.

Anxiety: The degree of anxiety the client is experiencing also may influence the client's response to pain. It is not possible to separate the mind from the body, so pain is always has both physiologic and psychological components. When anxiety is high pain is felt greater. Emotionally healthy persons are usually able to tolerate moderate or even severe pain than those whole emotions are less stable.

Fatigue: Fatigue heightens perceptions of pain. This intensifies pain and decreases coping abilities. Pain is often experienced less after a restful sleep than at the end of a long day.

Attention: The degree at which a client focuses on pain can influence pain perception. Increased attention has been associated with increased pain, whereas distraction has been associated with a diminished pain response. This concept is one that nurses apply in various pain relief measures such as relaxation, guided emergency and massage.

Previous experience: Each person learns from painful experiences. Previous experience does not necessarily mean that a person will accept pain more easily in the future. If a person has had frequent episodes of pain without relief or bouts of severe pain, anxiety or even fear may occur. In contrast if a person had repeated experience of pain, may be better prepared to tolerate or take necessary actions to relieve pain to some extent.

Coping style: The experience of pain can be lonely, when client experiences pain in health care setting such as hospitals, the loneliness can be unbearable. Frequently client feels a loss of central pain and an inability to control their environments or the outcome of events coping style thus influences the ability to deal with pain.

Family and social support: Parents and attitudes of significant others also affect pain response. People in pain often depend on family members for support, assistance or protection. An absence of family members or friends can often make the pain more stressful. For children presence of parents is very essential.

There are different ways to define types of pain, which include according to onset, duration, severity, modes of transmission, location, causation and causative force. The examples of which are as follows:

• Onset or time of occurrence, e.g. postoperative pain
• Duration, e.g. chronic pain or acute pain
• Severity or intensity, e.g. severe, mild or scored (0 to 10 on a scale)
• Location or source, e.g. superficial, deep or central pain
• Causation, e.g. pain due to receptor stimulation or nerve damage, or psychophysiologic pain
• Causative force or agent, e.g. spontaneous, self inflicted or other pain The common terms used to classify pain are as follows.

Noninvasive relief measures consist of cognitive behavioral strategies and physical modalities that use cutaneous stimulation. These treatments can be used to supplement pharmacological therapy and other modalities to control pain. Clients and their families can also be instructed to utilize these treatments at home and in inpatient settings.

Cognitive-behavioral interventions: The cognitivebehavioral interventions influence the cognitive and the motivational-affective components of pain perception. These methods cannot only help influence the level of pain, but also help the client gain a sense of self-control.

Trusting nurse-client relationship: Establishing a therapeutic relationship is the foundation for effective nursing care. The clients most likely to be comfortable are those who trust their nurses to be there, to listen, and to act.

Relaxation: Relaxation techniques (a variety of methods used to decrease anxiety and muscle tension) result in decreased heart rate and respiratory rate, and decreased muscle tension. The body's response to pain is almost "tricked" into reversing itself when relaxation exercises are implemented.

Relaxation exercises help reduce pain by decreasing anxiety and decreasing reflex muscular contraction. There are a wide variety of relaxation techniques, including focused breathing, progressive muscle relaxation, and meditation. Simple techniques should be used during episodes of brief pain (e.g. during procedures) or when pain is so severe that the client is unable to concentrate on complicated instructions.

To teach simple relaxation techniques, the nurse can instruct the client to: (i) take a deep breath and

hold it; (ii) exhale slowly and concentrate on going limp; and (iii) start yawning. The yawning triggers a conditioned response in the client (i.e. the body associates yawning with relaxation and will relax when the client yawns). The technique can be enhanced if the nurse starts yawning. It is so contagious that even the client compromised by severe pain will usually start yawning with the nurse.

A more complex technique is progressive muscle relaxation, a strategy in which muscles are alternately tensed and relaxed. This type of technique is especially useful for clients who do not know what muscle relaxation feels like. By purposely contracting and releasing the muscle groups, the client is able to compare the difference and identify feelings of relaxation. Meditative relaxation techniques are also available, including audiotapes sold in most bookstores.

Relaxation is a learned response. The more frequently the client practices these techniques, the more skilled the body will be in learning to relax. Ideally, the best time to teach the client these methods is when pain is controlled or before the pain occurs (e.g., in the preoperative period).

Reframing is a technique that teaches clients to monitor their negative thoughts and replace them with more positive ones. For example, teach a client to replace an expression such as, "I cannot stand this pain, it's never going away", with one such as, "I've had similar pain before, and it's gotten better".

Distraction: Distraction focuses one's attention on something other than the pain, therefore placing pain on the periphery of awareness. Successful or distraction does not eliminate the pain; it makes it less troublesome. The main disadvantage of distraction is that as soon as the distractive stimuli stop, the pain returns in full force. For this reason, the most appropriate use of distraction techniques is for the relief of brief, episodic pain. It can be effective for procedural pain or the period between administration of an analgesic and the onset of the drug. Examples of distraction include the following:

• Active listening to recorded music (have the client tap fingers in rhythm to the beat)
• Reciting a poem or rhyme (children do this well)
• Describe a plot of a novel or movie
• Describe a series of pictures

Guided imagery: Guided imagery uses one's imagination to provide a pleasant substitute for the pain. It incorporates features of both relaxation and distraction. The client imagines a pleasant experience, such as going to the beach or the mountains. The experience should use all five senses to fully involve the client in the image.

The images chosen need to be ones that are pleasant for the client. Describing an ocean cruise would not be appropriate for a person who becomes seasick.

Humor: The old saying, "Laughter is the best medicine," carries some truth to it. Although there is nothing very funny about pain, laughing has been shown to provide pain relief. The act or laughing can cause distraction from the pain, induce relaxation by taking deep breaths and releasing tension, release endorphins, and provide a pleasant substitute for pain. This technique can be implemented by encouraging the client to watch humorous movies, read funny books, or listen to comedy routines. Because different people see humor in different types of situations, be sensitive to what the client views as funny.

Biofeedback: Biofeedback is a method that may help the client in pain to relax and relieve tension. Individuals learn to influence their physiological responses to stimuli and thus alter their pain experience.

Cutaneous stimulation: The technique of cutaneous stimulation involves stimulating the skin to control pain. It is theorized that this technique provides relief by stimulating nerve fibers that send signals to the dorsal horn of the spinal cord to "close the gate". The main advantage of these therapies is that many techniques are easy for the nurse to implement and easy to teach the client and family to perform. They are not usually meant to replace analgesic therapy, but to complement it.

Hot and cold application: In addition to stimulating nerves that can block pain transmission, superficial heat application increases circulation to the area, which promotes oxygenation and nutrient delivery to the injured tissues. It also decreases joint and muscle stiffness. Heat is contraindicated in cases of acute injury because it can increase the initial response of

edema. It is also contraindicated in rheumatoid arthritis flare-ups and over topical applications of mentholated ointments. Heat treatments should be limited to 20- to 30-minute intervals because maximum vasodilatation occurs in that time.

Teach the client or family that hot or cold applications:

• Must have at least one layer of towel between the heating or cooling device and the skin.
• Should be placed on the skin only for short periods.
• Should not be applied to tissue that has been exposed to radiation therapy.

Cryotherapy (cold applications) induces local vasoconstriction and numbness, therefore altering the pain sensations. It is contraindicated in any condition where vasoconstriction might increase symptoms (e.g., peripheral vascular disease). For best results, cold therapy should be limited to 20 - to 30 -minute intervals. Either heat or cold can be used as cutaneous stimulation unless one is specifically contraindicated. Cold often provides faster relief. If the client has used heat or cold before, incorporate the modality that the client believes will be the most effective. Combining the two might provide better relief. An example of this would be to apply a hot pack for 4 minutes, followed by an ice pack for 2 minutes, repeated four times. In a hospital setting, a physician order is required for this therapy.

Acupressure and massage: One of the first responses to pain is to rub the painful part. People seem to instinctively understand the pain-relieving aspects of this intervention. In addition to blocking the pain transmission through nerve stimulation, massage can also promote relaxation. Acupressure is a type of massage that consists of continuous pressure on or the rubbing of acupuncture points. It is based on the same principles as acupuncture, but needles are not used. Massage also provides a form of nonverbal communication that can be therapeutic on its own.

Mentholated rubs: Ointments or lotions containing menthol are thought to provide relief by providing a counter irritation to the skin. The menthol gives the client the perception that the temperature of the skin has changed (becoming either warmer or cooler). This alters the sensation of pain or provides a distraction from the pain. Client response varies to mentholated rubs: some gain effective relief, but others have poor results. Their use is contraindicated on broken skin, on mucous membranes, or if pain increases.

Transcutaneous electrical nerve stimulation (TENS) is the process of applying a low-voltage electrical current to the skin through cutaneous electrodes. This modulates pain transmission, as do other cutaneous stimulation methods, but also distracts the client from pain. Research supports the effectiveness of using TENS for the relief of postoperative pain. It has also been used successfully in many pain syndromes (e.g. chronic low-back pain, menstrual cramps, temporomandibular joint (TMJ) syndrome, phantom limb pain, and others). It is administered by specially trained health professionals, usually a physical therapist. Other modalities of pain management should not be abandoned while a trial of TENS occurs.

• No electrodes should be placed in the area over or surrounding demand cardiac pacemakers.
• No electrodes can be placed over the uterus of a pregnant woman.

Exercise: Exercise is an important treatment for chronic pain because it helps mobilize joints, strengthens weak muscles, and helps restore balance and coordination. Do not use passive range of motion if it increases discomfort or pain. Immobilization is frequently used to stabilize fractures or for clients with episodes of acute pain. Prolonged immobilization can lead to muscle atrophy and cardiovascular conditioning.

Psychotherapy: Psychotherapy may be beneficial to some clients, particularly those:

• Who are clinically depressed
• Who have a history of psychiatric problems
• Whose pain is difficult to control.

Some psychotherapists use hypnosis (altered state of consciousness when a person is more receptive to suggestion) to help clients alter pain perception. Hypnosis can be effective but should be used only by specially trained professionals.

Positioning: The final noninvasive technique is proper positioning and body alignment. Moving the client with the least possible stress on joints and skin will minimize exposure to painful stimuli. This includes supporting joints appropriately and maintaining wrinkle-free sheets.

Invasive interventions are meant to complement behavioral, physical, and pharmacological therapies in those clients who do not obtain relief from those measures alone (AHCPR, 1994). Invasive measures are indicated primarily for chronic cancer pain and in some cases of chronic benign pain. These procedures are usually tried only when noninvasive measures have been attempted first with poor results.

Nerve block: Neural blockade is the process of injecting a local anesthetic or neurologic agent into the nerve. An anesthetic agent may be injected to act as a diagnostic tool in order to identify the nerves involved in a pain syndrome. A neurolytic agent is a chemical agent that causes destruction of the nerve and, therefore, creates an interruption in the pain signal.

Neurosurgery: Neurosurgical measures for pain control include neurostimulation procedures and destructive or ablative procedures, Neurostimulation procedures involve the implantation of electrical stimulation devices that send impulses to different parts of the nervous system. Some of these devices stimulate areas of the brain: others stimulate the spinal cord. Relief is thought to be provided by blocking the afferent fiber input at the spinal cord level or by stimulating release of endorphins using the body's ability to modulate pain.

Destructive or ablative procedures are used to destroy part of the nervous system that conducts pain. By interrupting the pain signal, it is prevented from reaching the cortex where realization of pain occurs. These procedures are reserved for clients with terminal illness.

Radiation therapy: Radiation can be used as a palliative measure for pain relief in clients with cancer. It can relieve both metastatic pain and pain caused by tumors at the primary cancer site. It enhances other pain management strategies, such as analgesic therapy, because it is aimed specifically at the cause of the client's pain. When administered for pain relief, the smallest dose of radiation is utilized to minimize side effects.

Acupuncture: Acupuncture is the insertion of small needles into the skin at specific (hoku) sites. The sites are chosen after the practitioner takes a detailed history and uses traditional Asian diagnostic techniques. The needles used for acupuncture have rounded ends that enter the skin without cutting the tissue. The practitioner may twirl or vibrate the needles manually or electrically. It is important that the nurse keep an open mind when the client chooses this therapy, or the client may be reluctant to discuss its use.

Evaluating pain management interventions is ongoing, focusing primarily on the client's subjective reports. Objective data to evaluate pain management include the following:

• Continuing use of pain assessment tools
• Client's facial expression and posture
• Presence (or absence) of restlessness
• Vital sign monitoring

Pain may be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage", and "whatever the client says it is, existing whenever the client says it does".

The gate control theory proposes that several processes (sensory, motivational-affective, and cognitive) combine to determine how a person perceives pain.

Assessment of pain helps establish a baseline of data and helps evaluate the effectiveness of the interventions.

Factors influencing pain perception include age, previous experience with pain, and cultural norms.

The subjective data to gather include location of pain, onset and duration, quality, intensity (on a scale of 0 to 10), aggravating and relieving factors, and how pain affects the activities of daily living.

When providing pain relief measures, the nurse chooses therapies suited to the client's unique pain experience, McCaffer (1979) suggests nine useful guidelines for pain therapy. The following guidelines are eleven which include nine.

Establish a relationship of mutual trust: Always believe the client and try to convey concern. An adversial relationship between nurse and client lessens the effectiveness of pain therapies.

Use different types of pain relief measures: Using more than one therapy has an additive effective reducing pain. In addition, the character of pain may change throughout the day, requiring several different therapies.

Provide pain relief measures before pain becomes severe: It is easier to prevent severe pain than to relieve it after it exists. Giving analgesics half an hour before, client must walk or perform an activity is an example of controlling pain early.

Consider the client's ability or willingness to participate in pain relief measures: Some client cannot actively assist with pain therapy because of fatigue, sedation or altered level of consciousness. However, there are variations of pain-relief measures that require little effort, such as relaxation exercises in bed or listening to music as a distraction. The nurse will not relieve pain by forcing an unwilling patient to participate in therapy.

Choose pain-relief measures on the basis of the client's behavior reflecting the severity of pain: It would be a poor judgment to administer a patient narcotic if a client has only mild pain. The nurse carefully assesses the client's comments and behavior before choosing pain therapy. Some clients acquire relief from severe pain after using only mild analgesics. Only the client can determine the potency of an effective therapy.

Use measures that the client believes are effective: The client is the expert of pain. The client may have ideas about measures to use (e.g. rubbing lotion on a swollen finger) and times to use them will make pain therapy successful.

If a therapy is ineffective at first, encourage client to try again before abandoning it: Often, anxiety or doubt prevents a therapy from relieving pain, or the measure may require adjustment or practice to become effective. The nurse should be patient and understanding in helping the client learn to use measures that do not afford immediate relief.

Keep an open mind about what may relieve pain: New ways are often found to control pain. There is still much to be learned about the pain experience. Rejecting nonconventional therapies leads to mistrust. The nurse should se to it that sure all therapies are safe.

Keep trying: The nurse can easily become frustrated when efforts at pain relief fail. The nurse should not abandon the client when pain persists but reassess the situation and consider alternative therapies.

Protect the client: A pain therapy should not cause more distress than the pain itself. The nurse always observes the efforts response to therapy. The nurse's aim is to relieve pain without disabling the client mentally, emotionally or physically.

Educate the client about the pain: When possible, the nurse should explain the cause of the pain, time of occurrence, duration and quality and ways to gain relief. Education promotes the prevention of pain.

The basic nursing responsibility is protecting the client from harm. One simple way to promote comfort is by removing or preventing painful stimuli. The following measures can be performed by the nurse to assist in pain control:

• Tighten and smooth wrinkled bed linen
• Reposition drainage tubes/ other objects on which patient is lying
• Place warm bath blankets for coolness
• Loosen constricting bandages (unless specifically applied as a pressure dressing)
• Change wet dressings
• Position the client in an anatomical alignment
• Check temperature of hot or cold applications including bath water
• Lift client on bed-do not pull. Patient up in bed; handle gently
• Position patient correctly on bed pain
• Avoid exposing skin or mucous membrane to irritants (e.g. diarrheal stool, wound drainage)
• Prevent urinary retention by keeping Foley's catheters patent and free-flowing
• Prevent constipation with fluids, diet and exercises.

Nurse's Role in administration of analgesics: The nurse spends the most time with the client in pain and is the team member who most often assesses the effectiveness of pain control interventions. When

analgesics are prescribed, the nurse often has choices of drug, route, and interval. For example, the postoperative client may have the following orders:

• Morphine 10-15 mg IM or IV q2-4h pm severe pain
• Vicodin i-ii tabs q3-4h pm moderate pain

When this client complains of pain, which analgesic should the nurse administer? Which route? Which dose? How frequently? The nurse has a large responsibility in making these decisions but also has autonomy in making these decisions. Each nurse may make a different decision, often based on the nurse's own biases.

The responsibilities of the nurse in administering analgesics includes:

• Determine whether to give the analgesic, and if more than one is ordered, which one.
• Assess the client's response to the analgesic, including assessing the effectiveness in pain relief and occurrence of any side effects.
• Report to the physician when a change is needed, including making suggestions for changes based on the nurse's knowledge of the client and pharmacology.
• Teach the client and family regarding the use of analgesics.

The drugs used to relieve pain work by altering pain sensation, depressing pain perception or modifying the patient's response to pain as the nurse has considerable control over .and responsibility for the effective use of medicines to reduce pain, knowledge of the drugs used in pain control, their routes of administration and side effects are needed. Examples of analgesic are of four types as follows:

1. Non-narcotic analgesics

• Acetaminophen (Tylenol, Danol)
• Acetylsalicylic acid (Aspirin)
• Choline magnesium trisalicylate (tritisate)

2. NSAIDs

• Ibuprofen (Brufen)
• Naproxen (Naprosyn)
• Indomethacin
• Tolmetin
• Piroxicam

3. Narcotic analgesics

• Meperidine
• Methylmorphine (Codiene)
• Morphine sulfate (Morphine)
• Fentany (Sublimaze)
• Butorphanol (Butarin)
• Hydromorphone HCl

4. Adjuvants

• Amitriptyline
• Hydroxyzine
• Caffeine
• Chloropromozine
• Diazepam

There are four types of analgesic as mentioned below which include: (i) non-narcotic analgesics; (ii) NSAIDs; (iii) opioids and (iv) adjuvants or coanalgesics. Non-narcotic and NSAIDs provide relief for mild and moderate pain.

Principles of administering analgesics: Principles should be applied in the administration of analgesics, no matter which one is given.

Establishing and maintaining a therapeutic serum level is important. Peaks and valleys often occur when analgesics are administered in the traditional PRN (as needed) manner. When the dose is administered on an intermittent schedule, a larger dose is often required, causing the client to have a peak serum drug level in the sedation range. The client must wait for the return of pain before requesting the next dose of analgesic. Depending on the length or time it takes to obtain the medication and, once taken, to re-establish an adequate blood level, there could be a period of up to an hour or so without adequate pain control.

Preventive approach: Pain is much easier control if treated when it is anticipated or at a mild intensity. Once pain becomes severe, the analgesics ordered may not be effective enough to relieve it. Many clinicians still teach their clients to wait to take medication until they are sure they really need it. This practice leads to uncontrolled pain. There are two ways the preventive approach may be implemented:

• ATC (around the clock): When pain is predictable, for example, the first few days following surgery or with chronic cancer pain, the medication is administered on a scheduled basis. This prevents the peaks and valleys of serum drug level that can

lead to oversedation or toxicity and recurrence of pain, respectively. If the analgesics are ordered by the physician to be given PRN, it can still be a nursing measure to administer the drugs ATC, as long as they are given within the time constraints of the order.

• PRN (Latin for pro re nata, which means "as required"): Pain is not always predictable: therefore PRN dosing may be required. For some clients this may be used in addition to scheduled dosing for "breakthrough" pain (pain that surpasses the level of analgesia, or pain relief without anesthesia, that the steady level of analgesics is providing). Examples of this include a cancer client on prolonged-release morphine who needs extra analgesics to participate in activities such as shopping or receiving visitors. Another example would be the orthopedic client who is receiving regularly scheduled analgesics for postoperative pain who needs additional pain relief for therapy sessions. In order to implement the preventive approach with PEN dosing, the medications should be given as soon as the pain appears, or when it is anticipated to begin.

The act of breathing involves two interrelated processes, ventilation and respiration-ventilation is the movement of air into and out of lungs. Respiration refers to the exchange of oxygen and carbon dioxide across cell membrane. The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and carbon dioxide between the atmosphere and blood. The respiratory system is divided into two parts, i.e. the upper respiratory tract and lower respiratory tract. The upper respiratory tract includes the nose, pharynx, adenoids, tonsils, epiglottis, larynx and trachea. The lower respiratory tract consists of bronchi, bronchioles, alveolar ducts and alveoli. With the exception of the right and left main stem bronchi, all lower airway structures are contained in the lungs. The right lung is divided into three lobes-upper, middle and lower and the left lung into two lobes-upper and lower. The structure of the chest walls (ribs, pleura, muscle of respiration) are also essential to respiration.

Respiratory assessment should be tailored to the individual's health status. The most common symptoms or reasons, a person seeks health care include dyspnea, cough, sputum production, hemoptysis, wheezing or chest pain. Upper airways symptoms may include obstruction of noses, nasal discharge, sinus pain, sore throat or hoarseness.

Dyspnea means breathlessness, but the terms used to describe difficult or labored breathing observable by others. It may cause other problems such as constipation or poor nutrition, as well as psychosocial problem related to poor self-esteem or changes in lifestyle. Individuals experiencing pulmonary dysfunctions, such as breathlessness, tend to perceive their illness in terms of its impact on their ability to carry-out activities of daily living. Which includes:

• Bathe, dress and groom - Perform chores or hobbies
• Walk or exercise
• Prepare meals and rest
• Getting into home or climbing stairs
• Sleep
• Get to the bathroom
• Maintain family and social relationships
• Maintain employment
• Perform scanality
• Attend activities away from home

Analysis of dyspnea according to its time and characteristics. i. Timing: Chronic or acute, episodic or paroxysmal, onset, duration and frequency. ii. Characteristics:

• Perceived severity

• Phases of respiratory cycle-Inspiratory, expiratory, throughout cycle. iii. Other symptoms related to dyspnea: iv. Associated factors:

• Time of day

• Seasonal or weather changes

• Environmental irritants

• Anxiety

• Body position-paroxysmal nocturnal dyspnea (PND). Sudden onset while sleeping in recumbent position.

• Orthopnea: Breathlessness on assuming recumbent position.

• Activity.

Coughing has two main functions. It protects the lungs from aspiration and it helps propel foreign matter and excess mucus up through the airways. The individual can describe the cough in terms of timing and characteristics as follows: i. Timing: Chronic, acute, paroxysmal (periodic forceful episode difficult to control) onset (gradual or sudden). ii. Characteristics:

• Perceived severity
• Pattern, occasional, upon rising, with activity (talking, exercising, eating). iii. Quality:
• Productive, non-productive
• Dry progression to productive
• Barking
• Hoarse
• Hacking iv. Other symptoms:
• Chest tightness
• Fever, coryza
• Choking.

The mucous blanket lines the epithelial layer of the trachobronchial tree and cleanses it of inhaled particles and debris. Mucus is produced by the globet cells and submucosal glands. The cilia propel the mucous (which contains foreign particles, pus, blood and debris) upward toward the pharynx where it is coughed up, suctioned or swallowed. Normal sputum is clear and thin and average $100 \mathrm{ml} /$ day. However, individuals with pulmonary disease often have sputum associated with these conditions making it important to assess the baseline super characteristics, describes as thick, viscous (gelatanious) tenacious (sticky), frothy, mucoid (colorless, clear, non-infectious watery, mucopurulent, and casts (from bronchioles, rubbery).

The mucopurulent sputum may be:

• Creamy yellow: Staphylococcal pneumonia.
• Green: Pseudomonas pneumoniae
• Current jelly: Klebsiella pneumoniae.
• Rusty: Pneumococcal pneumonia.
• Pink frothy: Pulmonary edema

The quantity of amount of sputum may be teaspoon, tablespoon or cups used as a measurement.

Hemoptysis is the coughing up of blood or bloodtinged sputum. It may contain air bubbles. The source of bleeding may be from anywhere in the upper or lower airways or from the lung parenchyma. Blood that originates in the GI tract and is coughed up as dark brown or resembling coffee grains in appearance termed as "hematemesis". It is usually never frothy, may be mixed with food particles, pH acidic dark-red or coffee colored. Bleeding from the nares (epistaxis) should be assessed as a cause for coughing up blood or vomiting of blood.

In hemoptysis, blood is usually frothy, pH alkaline, bright red. The coughing up of 400-1600 ml of blood in 24 hours period is considered massive and severe, needs immediate medical attention.

Wheezing is a continuous high-pitched, whistling sound produced when air passes through narrowed or obstructed airways. It is generally occurring during expiration, however, wheezing can be heard throughout respiratory cycle. Wheezing is usually heard with a stethoscope; however, wheezing may be audible to the person or heard by others in close proximity to the person. An analysis of this symptom should include factors that can cause bronchospasm and produce wheezing such as asthma, exposure to physiological irritants, stress, anxiety. Snoring or stridor cloud snoring may be experienced.

Chest pain can result from several conditions. Chest pain may be cardiac origin. The chest pain of pulmonary origin can originate from the chest wall. Parietal pleura or lung parenchyma. The characteristics of pulmonary chest pain are:

• Pain from the chest wall is well-localised, constant ache increasing with movement. It may be due to trauma, cough and herpes zoster.
• Pain is parietal pleura is a sharp, abrupt onset, increasing with inspiration or with sudden ventilatory effort (cough, sneeze) unilateral.
• Pain from lung parenchyma is dull, constant poorly localised in benign pulmonary tumors and carcinoma; well-localised sharp, sudden onset in pneumothorax; sudden onset, increasing stabbing pain on inspiration, may radiate in cases of pulmonary embolus and infarction. In addition to review of symptom or reason the person is seeking health care, the person should be interviewed about risk factors associated with respiratory dysfunction, including smoking, past pulmonary illnesses or exposure to respiratory infections, predisposition to genetic disorders, exposure to environmental irritants (dust, fume, gases, etc.) and the psychosocial effects of respiration disorders.

The emotional responses include anxiety, depression, hostility, fear or panic, etc. and ask the person's problems with swallowing and ambulating as well as neuromuscular diseases.

The common abnormalities of the thorax and lungs found by physical examinations are as follows:

• Pursed-lip breathing: Is an exhalation through mouth with lips pursed together to slow exhalation. As seen in COPD, asthma suggests increasing breathlessness. Strategy taught is slow expiration, decrease dyspnea.
• Tripod position: Inability to be flat, i.e. leaning forward, with arms and elbows supported on overbed table. Seen in COPD, asthma in exacerbations, pulmonary edema, indicates moderate to severe respiratory distress.
• Accessory muscle use: In intercostal retractions neck and shoulder muscles are used to assist breathing. Muscles between ribs pull in during respiration. Due to COPD, asthma in exacerbationsecretion retention, indicate severe respiratory distress, hypoxemia.
• Splinting: A voluntary decrease in tidal volume to decreased pain on chest expansion. It is due to thoracic or abdominal incisions, chest trauma, plurasy.
• Increased: AP diameter AP chest diameter equal to the lateral, slope of ribs more horizontal $\left(90^{\circ}\right)$ or spine. One to COPD, asthma, cystic fibrosis, lung hyperinflation, advanced age.
• Tachypnea: Increased rate of 20 breaths/minute, $>25$ breath/minute in elderly. Due to fever, anxiety, hypoxemia, restrictive lung disease. Magnitude of increasing above normal rate reflects increased work of breathing.
• Kussmaul's respiration: Regular rapid and deep respirations are due to metabolic acidosis. Increase in rate aids body in $\mathrm{CO}_{2}$ excretion.
• Cyanoses: Refer to a bluish color of skin best seen in earlobes, under eyelids or nailbeds. It is due to decreased oxygen transfer of lungs, decreased cardiac output, nonspecific unreliable indicator.
• Clubbing of fingers: Refer to increased depth, bulk, sponginess, of distal digit finger. It is due to chronic hypoxemia, cystic fibrosis, lung cancer, bronchiectasis.
• Abdominal paradox: An inward (rather than normal outward) movement of abdomen during inspiration. It is due to insufficient and ineffective breathing pattern-nonspecific indicator of severe respiratory distress.

• Tracheal deviation is a leftward or rightward movement of trachea from normal midline position. It is nonspecific indicator of change in position of mediasternoid structure, medical emergency if caused by tension pneumothorax.
• Altered tactile fremitus is increased or decreased in vibrations. It is due to increased in pneumonia, pulmonary edema; decreased in pleural effusion, atelectic area, lung hyperinflation, absent in pneumothorax, large atelectasis.
• Altered chest movements, i.e. unequal or equal but diminished movement of two sides of chest with inspiration. Usually unequal movement caused by atelectasis, pneumothorax, pleural effusion, splinting, equal but diminished movement caused by barrel chest, restrictive disease and neuromuscular disease.

• Hyper-resonance is loud, laver-pitched sound over areas that normally produces a resonance sound. It is due to lung hyperinflation (COPD), lung collapse (pneumothorax) air trapping (asthma).
• Dullness is medium-pitched sound over areas that normally produce a resonant sound. It is due to increased density (pneumonia, large atelectasis). Increased fluid pleural space (pleural effusion).

• Fine crackles are series of short explosive, highpitched sounds heard just before the end of inspiration: result of rapid equalisation of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open similar sound to that made by rolling hair between fingers just behind ear. Can be heard in fibrosis (asbestos interstitial edema, early pulmonary edema), alveolar filling (pneumonia) loss of lung volume (atelectasis), early phase of congestive heart failure.
• Coarse crackles are series of short, low-pitched sounds caused by air passing through airway intermittently occluded by mucus unstable bronchial wall of fold of mucosa, evident on inspiration and at times, expiration; similar sound to bowling quality with more fluid. These can be heard in congestive heart failure, pulmonary edema, pneumonia with severe congestion, COPD.
• Rhonchi are continuous rumbling, snoring, or rattling sounds from obstructions of a large airways with secretions most prominent on expiration; change often evident after coughing or suctioning. These are heard in COPD, cystic fibrosis, pneumonia, bronchietasis.
• Wheezing are continuous musical sound of constant pitch: result of partial obstruction of larynx or trachea. It is due to epiglottis, vocal cord edema after extubation, foreign body.
• Absent breath sounds, no sound evident over entire lung or area of lung. It is due to pleural effusion, main stem bronchi, obstruction, large atelectasis, pneumonectomy, lobectomy.
• Pleural friction rub is cracking or grating sound from roughened inflamed surfaces of the pleura rubbing together, evident during inspiration. It is due to pleurasy, pneumonia, pulmonary infarction.
• Bronchophony, whispered pectoriloquy a spoken or whispered syllable more distinct than normal on auscultation as in pneumonia.
• Egophony is a spoken "e" similar to "a" on auscultation because of altered transmission of voice sounds seen in pneumonia, pleural effusion.

i. Hemoglobin test reflects amount of hemoglobin available for combination with oxygen. Venous blood is used. The normal level of adult man is $135-180 \mathrm{~g} / \mathrm{dl}(13.5-18 \mathrm{~g} / \mathrm{l})=$ Normal level of adult woman is $12-16 \mathrm{~g} / \mathrm{dl}(120-160 \mathrm{~g} / \mathrm{l})$. The nursing responsibilities during the procedure is to explain the procedure and its purpose. No special care is required. ii. Hematocrit test reflects ratio of red blood cells to plasma increased hematocrit (polycythemia) found in chronic hypoxemia. Venous blood is used. Normal for adult man is 40-54 percent and woman is $38-47$ percent. The nursing responsibility is as in $\mathrm{HB} \%$. iii. Antitrypsin assay is valuable in the identification of individuals with the genetic abnormality that leads to emphysema. This is a globulin that inhibits certain enzymes. The normal values of al-antitrypsin assay. MM genotype: 2.1-3.8 u/ml M2 phenotype: $1.05-2.1 \mathrm{u} / \mathrm{ml}$ 22 phenotype: $0.5-0.7 \mathrm{u} / \mathrm{ml}$ The nursing care includes as in hemoglobin. No food or fluid restrictions are necessary. iv. Complete blood count: The normal counts of RBCs in male 4.6-6.2 million/D. 4.2-5.4 million/ L in females. The normal level of WBC 4.0-11.0 $\times 103 / \mathrm{L}$. v. Arterial blood gases (ABGs): Arterial blood is obtained through puncture of radial or femoral artery or through arterial catheter. ABGs are performed to assess acid-base-balance, ventilation status, need for oxygen therapy, change in oxygen therapy, or change in ventilation settings. Continuous ABG monitoring is also possible via

a sensor or electrode inserted into the arterial catheter. Nursing responsibility in this test, thus includes. Explain the purposes of the test and its procedure to the patient in using oxygen (percentage, $\mathrm{L} / \mathrm{min}$ ). Avoid changing it for 20 minutes before obtaining sample. Assist with positioning (e.g. palm up, wrist slightly hyperextended if radial artery is used). Collect blood into heparanised syringe. To ensure accurate results, expel all air bubbles, and place sample in ice, unless it will be analysed in less than 1 minute. Apply pressure to artery for 5 minutes after specimen is obtained to prevent hematoma at the arterial puncture site. The normal values, parameters of ABGs are:

• Acid-base-balance measured as pH (hydrogen ion concentration. Normal 7.357.45. Alkalemia increased 7.45. Acedemia decreased 7.35 .
• Oxygenation $\mathrm{PaO}_{2}$ (partial pressure of dissolved $\mathrm{O}_{2}$ in blood. Normal $80-100 \mathrm{~mm}$ Hg. Hyperoxemia 100 mm Hg , hypoxemia ${ }^{-}$ 80 mm Hg .
• Ventilation $\mathrm{SaO}_{2}$ percentage of $\mathrm{O}_{2}$ bound hemoglobin. $\mathrm{PaCO}_{2}$ partial pressure of $\mathrm{CO}_{2}$ dissolved in blood. The normal $\mathrm{SaO}_{2}$ is 95-98 per cent. The normal $\mathrm{PaCO}_{2}: 35-45 \mathrm{~mm} \mathrm{Hg}$ hypercapnia 45 mm Hg . Hypocapnia ${ }^{-} 35$ mm Hg . vi. Oximetry: Test monitors arterial or venous oxygen saturation device attached to the ear lobe, finger or nose for $\mathrm{SPO}_{2}$ monitoring or is contained in a pulmonary artery catheter for $\mathrm{SVO}_{2}$ monitoring. Oximetry is used for continuous monitoring in ICUs, inpatient and outpatient sortings and exercise testing. The nursing responsibilities include, applying probe to finger, forehead, earlobe or bridge of nose. When interpreting $\mathrm{SPO}_{2}$ and $\mathrm{SVO}_{2}$ values, first assess patient status and presence of factors that can alter accuracy of pulse oximeter reading. For $\mathrm{SPO}_{2}$, these include motion, low perfusion, bright lights, use of intravascular dyes, acryling nails, dark skin colour. For $\mathrm{SVO}_{2}$, these include change in $\mathrm{O}_{2}$ delivery or $\mathrm{O}_{2}$ consumptions. For $\mathrm{SPO}_{2}$ notify physician of $\pm 4$ percent change from baseline or decrease to less than 90 percent. For $\mathrm{SVO}_{2}$ notify physician of $\pm 10$ percent change from baseline or decrease to less than 60 percent.

The nursing responsibilities include explain purposes. Some tests require specimens, collected in consecutive days usually 4 ml of sputum is sufficient. Coughing upon awakening is more likely to result in collecting sputum and not saliva. Instruct individual to rinse the mouth with water, demonstrate effective deep breathing and coughing, have individual practice deep breathing and coughing, instruct individual to notify staff as the specimen is collected. Following are different tests and nursing care.

Single sputum specimen is collected in a sterile container. For diagnosing bacterial infection, select antibiotic and evaluate treatment. Here instruct patients on how to produce of good specimen for Gram stain test as given below if patients cannot produce specimen bronchoscopy may be used.

Staining of sputum permits classification of bacteria into gram- negative and gram-positive types. Results guide therapy until culture and sensitivity results are obtained. Here nurse instructs patient to expectorate sputum into the container after coughing deeply. Obtain sputum in early morning because secretions collect during night. If unsuccessful try increasing oral fluids, intake unless fluids are restricted. Collect sputum in sterile container (sputum trap) during suctioning or by aspirating secretions from the trachea. Send specimen to laboratory promptly.

Test is performed to collect sputum for acid-fast bacilli (AFB). A series of three early morning specimen is used. Nursing responsibility as in Gram stain and cover specimen and send to laboratory for analysis.

In this single sputum specimen is collected in special container with fixative solution. Purpose is to

determine presence of abnormal cells that may indicate malignant condition. The nurse should send specimens to laboratory promptly and take measure in other tests.

Test is used to screen, diagnose, and evaluate change. Most common views are posteroanterior and lateral. In this, nurse instructs patient to undress to waist, put on gown, and remove any metal between neck and waist.

Test is performed for diagnostic of lesions difficult to assess by conventional X-ray studies, such as those in the hilum, mediastenum, and pleura. Images show structures in cross-section. Nursing care is same as for chest X-ray.

Test is used for diagnosis of lesions difficult to assess by CT scan (e.g. lung apex near the spine). Here, nurse explains purpose, takes measures as in chest X-ray and instructs the patient to remove all metal (e.g. jewellery, watch) before test. It takes about an hour.

Test is used to identify areas of the lung not receiving air flow (ventilator) or blood flow (perfusion). It involves injection of radioisotope and inhalation of small amount of radioactive gas (Xenon). A gamma detecting device is used to record radioactivity. Ventilation without perfusion suggests pulmonary embolus. The nursing measures are as for chest X-ray. Also check for dye allergy. Obtain an accurate weight so that the dosage of radioactive agent can be calculated. No special care or precaution is needed afterwards (post test) because the gas and isotope transmit radioactivity for only brief interval.

Study is used to visualize pulmonary vasculature and locate obstructions or pathologic conditions such as pulmonary embolus. A radio-opaque dye is injected, usually through a catheter into the pulmonary artery or right side of the heart. Nursing measures same as chest X-ray. Know that dye injection may cause flushing, warm sensation, and coughing. Check pressure dressing site after procedure. Monitor blood pressure, pulse rate and circulation distal to injection site. Report and record significant changes.

Test is used to distinguish benign and malignant lung nodules. It involves IV injection of a radioisotope with short half-life. Nursing measures same as V/P.

This study is typically performed in outpatient procedure room. Flexible fiberoptic scope is used for diagnosis, biopsy, specimen collection, or assessment of changes. It may also be done to suction mucous plugs or to remove foreign objects. In this examination, the nurse instructs patient to be on NPO status for 6-12 hours. Obtain signed permit (consent). Give diazepam if ordered by physician before procedure to aid relaxation. After procedure, keep patient NPO until gag-reflex returns and monitor for laryngeal edema. If biopsy was done, monitor for hemorrhage and pneumothorax.

Test is used for inspection and biopsy of lymph nodes in mediastinal area. Nurse prepares patient for surgical intervention, obtains signed permit. Afterwards monitor as for bronchoscopy.

In lung biopsy specimen may be obtained by transbronchial or open-lung biopsy. This test is used to obtain specimens for laboratory analysis. Nursing measures same as bronchoscopy.

Test is used to obtain specimen of pleural fluid for diagnosis, to remove pleural fluid or to instill

medication. The physician inserts a large bore needle through chest wall into pleural space. Chest X-ray is always obtained after procedures to check pneumothorax. Nursing responsibility includes explaining procedures to patient and obtain signed permit prior to procedure. Position patient upright, instruct not to talk or cough, and assist during procedure. If large volume of fluid is removed, monitor for decrease in shortness of breath, send labelled specimen to laboratory.

It is used to valuate lung function. It involves use of a spirometer to diagram air movement as patient performs prescribed respiratory manoeuvres. Nurse has to avoid scheduling immediately after meals times. Avoid administration of inhaled bronchiodilator for 6 hours before procedure.

Explain procedure to patient. Provide rest after procedure.

Bronchitis is an inflammation of the lower respiratory tract that is usually due to infection and occurs most frequently in patients with chronic respiratory disease. Bronchitis can be acute or chronic bronchitis.

Acute bronchitis is an inflammation of the bronchi and usually the trachea (tracheobronchitis).

Acute bronchitis occurs most often in persons with chronic lung disease. It also occurs as an extension of the URI in persons without underlying any lung disease, and is therefore communicable. It may be caused by physical and chemical agents such as dust, smoke, or volatile fumes. As air pollution increases, the incidence of acute bronchitis increases.

Acute bronchitis is typically viral, but bacterial pathogens such as Streptococcus pneumoniae and Hemophilus influenzae may also cause bronchitis, either primary or secondary infections which includes:

• Viruses: Rhinovirus, adenovirus, influenza A and B, parainfluenza virus and respiratory syncytial virus (RSV).
• Bacteria: Streptococcus pneumonia, Hemophilus influenza Moraxella catarrhalis, Bordetella pertussis, Mycoplasma pneumonia, Chlamydia pneumoniae.

As a part of the inflammatory process, there is increased blood flow to the affected area, causing an increased in pulmonary secretions. A painful cough with sputum productions, low-grade fever, and malaise are common symptoms. The patient may have pain beneath the sternum caused by inflammation of the tracheal wall. Bronchitis without tracheitis never seen, and tracheobronchitis is more appropriate term for this condition. Symptoms usually last 1 for 1 to 2 weeks but may continue for 3 to 4 weeks. Rhonchi and wheezes heard on chest examination. If symptoms worsen and there is a high fever, shortness of breath, pleuritic chest pain (pain on inspiration) rapid respirations and rales or sign if consolidation on physical examination of the chest, pneumonia suspected.

Treatment of acute bronchitis is mainly supportive and includes the following:

• Codeine or dextromethorphan is prescribed for nocturnal cough.
• Bronchodilator therapy is prescribed for patients who are wheezing and for those whose peak expiratory rate prolonged, e.g. albuterol, or ipratropium.
• Decongestants and antihistamines are used sparingly, if at all, because they tend to dry secretions and make them more difficult to remove.
• Oral fluids intake of 2 to 3 litre per day is encouraged if there is no contraindications to it.
• Aspirin helps to reduce fever and alleviate some of the symptoms and inflammation.
• Patients who are smokers are urged to quit.
• Antibiotics are usually not prescribed unless there is evidence of bacterial infections.
• Rest is encouraged to give the body a chance to heal. Nursing care is supportive and is directed towards helping the patient with prescribed therapy and avoiding future infections. Emphasis on assisting the patient to cough effectively, assisting with comfort,

assisting with activities of daily living and teaching the patient and family.

To produce an effective cough, a deep inspiration must be followed by maximal expiratory effort against a closed glottis. This results in a tremendous increase in intrathoracic pressure. As glottis opens, mucus and inhaled particles are forced out of the airways at a high velocity. Persistent coughing can be annoying and tiring to the patient and those around him or her. Complications of persistent coughing includes, insomnia, exhaustion vomiting, urinary incontinence, rib or muscle trauma, pneumothorax, and fainting. If cough persists, give cough medication as prescribed. A semi-Fowler's position or high-Fowler's position usually facilitates breathing. Provide for good drainage of trachobronchial secretions and give antibiotics as ordered and assist in ADL.

Pneumonia or pneumonitis is an acute inflammation of the lung tissue (lung parenchyma).

Pneumonia is resulting from inhalation or transport via the blood-stream of infectious agents or noxious fumes or from radiation treatment. Pneumonia is classified according to whether infection was acquired in the community or in the hospital. Thus pneumonia is classified as "community acquired pneumonia (CAP) or hospital acquired pneumonia (HAP). HAP is also called nosocomial pneumonia. The causes of pneumonia are as follows. i. Community-acquired pneumonia caused by:

• Streptococcus pneumoniae
• Hemophilus influenzae
• Mycoplasma pneumoniae
• Respiratory viruses
• Chlamydia pneumoniae
• Legionella pneumophila
• Oral anaerobes
• Moraxella catarrhalis
• Staphylococcus aureus
• Nocardia
• Enteric aerobic gram-negative bacteria (e.g. Klebsiella)
• Fungi
• Mycobacterium tuberculosis. ii. Hospital acquired pneumonia caused by:
• Pseudomonas aeruginosa
• Enterobacter
• Escherichia coli
• Proteus
• Klebsiella
• Staphylococcus aureus
• Streptococcus pneumoniae
• Oral anaerobes.

The risk factors which predispose to pneumonia are:

• Smoking
• Air pollution
• Altered consciousness: Alcoholism, head injury, seizures, anesthesia, drug overdose
• Tracheal intubation (endotracheal intubations, tracheostomy)
• Upper respiratory tract infection
• Chronic diseases: Chronic lung diseases, diabetes mellitus, heart disease, uremia, cancer
• Immunosuppression
• Drugs (carciosteroids, cancer chemotherapy, immunosuppressive therapy after organ transplant)
• HIV
• Malnutrition
• Inhalation of aspiration of noxious substances
• Debilitating illness
• Bedrest and prolonged immobility
• Altered oropharyngeal flora.

The risk factors for hospital acquired pneumonia are:

• Residence in an ICU
• Mechanical ventilation (those who required 48 hours or more ventilation)
• Endotracheal intubation or tracheostomy
• Recent surgery
• Debilitation, i.e. malnutrition
• Invasive devices
• Neuromuscular disease
• Depressed level of alertness
• Aspiration
• Antacid use
• Age 60 or older
• Prolonged hospital stay
• Any serious underlying disease.

Normally, the airway distal to the larynx is sterile because of protective defence mechanisms. These mechanisms include:

• Filtration of air
• Warming and humidification of inspired air
• Epiglottis closure over the trachea
• Cough reflex
• Mucociliary escalator mechanism
• Secretion of immunoglobulin A
• Alveolar macrophages.

Pneumonia results in inflammation of lung tissue. Depending on the particular pathogen and the hosts' physical status, the inflammatory process may involve different anatomical areas of the lung parenchyma and the pleurae. The normal function of respiratory system and primary pathophysiology and clinical manifestation are as follows: i. Normally 'mucociliary system' cleanses inhaled air by trapping particles. In pneumonia, hypertrophy of mucous membrane lining lung, resulting in hypersecretions leads to increased sputum production and cough:

• Anerobic - Foul-smelling, sputum
• Klebsiella - Current Jelly color
• Staphylococcus - Creamy yellow
• Pseudomonas-Green
• Viral/mucopurulent

And bronchospasms from increased secretions, leads to localised or diffuse wheezing dyspnea. ii. Generally 'alveolocapillary membrane' exchanges oxygen-carbon dioxide. In pneumonia, there is increased permeability resulting in excess fluid in interstitial space, shows consolidation (in chest X-ray films) localised/bacterial; diffuse/ viral, and also there is decreased surface area for gas exchange leads to hypoxaemia. iii. Normally pleura maintains close approximation of lungs and chest wall; minimizes friction during lung expansion and contraction. In pneumonia there is inflammation of the pleura which shows, chest pain, especially on inspiration, pleural effusion, dullness on percussion, decreased breath sounds and decreased vocal fremitus. iv. Normally respiratory muscle expands and contracts chest wall and thus pleura and lungs. In pneumonia there is hypoventilation and respiratory acidosis (in presence of underlying disease) leads to decreased chest expansion and hypercapnoea and low arterial blood pH . v. The lung defense system protects normally sterile lung from invasion. In pneumonia there is bacteremia, shows elevated blood cell counting; leukocytes ( 15,000 to $25000 / \mathrm{mm}$ ), neutrophilia and tachypnoea and fever. In pneumococcal pneumonia there is congestion, red hepatisation and gray hepatisation.

CAP has been traditionally thought to present any two syndromes; typical and atypical, although the distinctions are not clear.

Typical pneumonic syndrome is characterised by sudden onset of fever, chills, cough productive of purulent sputum, and pleuritic chest pain (in some cases). On physical examination signs of pulmonary consolidations such as dullness, percussion, increased fermitus, bronchial breath sounds, and crackles may be found. In elderly or debilitated patient, confusion or stupor may be predominant. Usually two types of pneumonia caused by S. pneumoniae and H . influenzae.

The atypical syndrome is characterised by a more gradual onset dry cough, and extrapulmonary manifestation such as headache, myalgia, fatigue, sore throat, nausea, vomiting and diarrhea. On physical examination, crackles are often heard. This type of classically produced by mycoplasm, pneumonia and legonell chlamydia pneumonia. Viral pneumoniae are characterised by an atypical presentation with chills, fever, dry non-productive cough and extrapulmonary symptoms. Most of the pneumoniae run uncomplicated. If occurs, the complications are pneumonia including pleurisy, pleural effusion, atelectasis, delayed resolution, lung abscess, empyema, pericarditis, arthritis, meningitis and endocarditis.

History, physical examination and chest X-ray often provide enough information to take management decisions without costly laboratory tests. Diagnostic tests include:

• Chest X-ray film to confirm consolidation and distribution and pleural effusions.
• Sputum studies for culture and sensitivity if unable to obtain specimen by usual means, may use,
• Transtracheal aspiration,
• Bronchoscopy with aspiration, biopsy or bronchial brushings.
• Arterial blood gas studies or pulse oximetry.
• Hematology: WBC count, cole agglutinin and compliment fixation for viral studies.
• Thoracentesis to obtain pleural fluid specimen if pleural effusion is present. The possible nursing diagnosis on the basis and assessment will be:
• Airway clearance, ineffective $\mathrm{r} / \mathrm{t}$ decreased energy, fatigue, tracheobronchial inflammation.
• Impaired gas exchange r/t alveolar capillary membrane changes altered oxygen delivery.
• Pain r/t pleural inflammation, coughing paroxysms.
• Rest for infection r/t compromised lung defense system.
• Knowledge deficient r/t condition, treatment.
• Anorexia r/t infection process-sputum production.
• Altered nutrition/body requirement $\mathrm{r} / \mathrm{t}$ increased metabolic needs. Prompt treatment with the appropriate antibiotic almost always cures bacterial and mycoplasmal pneumonia. In uncomplicated cases, the patient responds to drug therapy within 48 to 72 hours. Indications for improvement including decreased temperature, improved breathing, and reduced chest pain.

Abnormal physical finding lasts for more than 7 days. The nursing intervention includes. i. Maintaining effective airway clearance

• Monitor for increased respiratory distress
• Assist patient to cough effectively
• If unable to clear down airway, suction airway using sterile technique
• Assist with nebuliser therapy
• Administer bronchiodilator as ordered. Monitor for side effects and response to therapy
• Change position frequently to assist in mobilising secretions
• Ensure fluid intake adequate to thin secretions. ii. Facilitate breathing

Help the patient breathe deeply and expand the chest to increase ventilation.

• Place the patient in position to facilitate breathing, usually upright or semiupright position.
• A pillow may be placed lengthwise at the patient's back to provide support and thrust thorax slightly towards allowing free use of the diaphragm.
• The patient who must be upright to breathe may find it restful to place head and arms on a pillow placed on an overbed table.
• For the patient with severe hypoxemia, side rails should be in place. The patient can use them to assisting about in bed.
• Some patients who breathe best when sitting up in a large armchair while leaning on a smaller chair. Placed in front of that. This chair is blocked to prevent it from slipping.
• Assist with ADL pacing activities to prevent fatigue and respiratory distress. iii. Administration of medication and treatment
• Before starting prescribed antibiotic, collect sputum for culture and blood for culture if ordered.
• Maintain antibiotic blood levels by giving antibiotic at scheduled time.
• Give medication prescribed to relieve pain. Codeine may be ordered because it is less likely to inhibit cough reflex than more potent narcotics.
• Begin oxygen therapy. iv. Administering oxygen therapy v. Promoting comfort
• Place in position of comfort, Preferably head of bed elevated 45 to 90 degrees.
• Assess character and location of chest pain.
• Administer analgesic for chest pain e.g. acetylsalicylic acid, acetominophen and codeine.
• Splint chest with hands when patient coughs.
• Administer frequent mouth care. Protect lips and nares with lubricants.
• Keep patient warm and dry and avoid chilling. vi. Preventing spread of infection.
• Standard precautions are used. vii. Facilitating learning.

The major teaching emphasis is on prevention.

• Assess patient's understanding of pneumonia with questions concerning such information

on how pneumonia is transmitted and risk factor.

• Teach proper handling of secretions. Cover nose and mouth with tissue when coughing or sneezing. Discard tissues in paper or plastic bag for disposal. Expectorate into specimen container provided.
• Stress importance of handwashing after coughing, sneezing and expectorating.
• Reinforce importance and follow-up care.
• Reinforce the need for immunization, i.e., inlfuenza vaccine and pneumococcal vaccine. (Pneumonia Polysaccaride vaccine is given only every 3 to 5 years. viii. Promoting adequate hydration and nutrition
• Encourage oral fluids. If patient is receiving IV fluids, monitor rate. Observe for signs of fluid volume deficit or excess.
• Ask patient what foods he or she would like to eat.
• Offer small, frequent feedings.
• Encourage high-carbohydrate and highprotein foods.

Tuberculosis is an infectious disease caused by mycobacterium tuberculosis. It usually involves the lungs, but it also occurs in the kidneys, bones, adrenal glands, lymph nodes and meninges and can be disseminated throughout the body.

Mycobacterium tuberculosis, a gram-positive, acidfast bacillary, is usually spread via air-borne droplets, which are produced when the infected individual coughs, sneezes or speaks. Once released into a room, the organisms are dispersed and can be inhaled. Brief exposure to a tubercle bacilli rarely causes an infection. Rather it is more commonly spread to the individual who has had repeated close contact with an infected person. It is not highly infective and transmitted. It usually requires close, frequent or prolonged exposure. The disease cannot be spread by hands, books, glasses, dishes or other fomites.

When an individual with no previous exposure to TB (negative tuberculin reactor) inhales a sufficient number of tubercle bacilli into the alveoli, tuberculosis infection occurs. The body's reaction to the TB bacilli depends on the susceptibility of the individual, the size of the dose and the virulence of the organisms. Inflammation occurs within the alveoli (parenchyma) of the lungs, and natural body defenses attempt to counteract the infection.

When the bacilli is inhaled, they pass down the bronchial system and implant themselves on the respiratory bronchioles or alveoli. The lower part of the lungs are usually the site of initial bacterial implantation. After implantation, the bacilli multiply with no initial resistance from the host. The organisms are engulfed by phagocytosis (initially neutrophils and later macrophages) and may continue to multiply within the phagocytes.

Macrophages ingest the organism and present the microbacterial antigens to the T cells. CD4 cells secrete lymphokine than enhance the capacity of the macrophages to ingest and kill bacteria. Lymph nodes in the hilar region of the lung become enlarged on their filter drainage from the infected site. The inflammatory process and the cellular reaction produce a small, firm, white nodules called the 'primary tubercle'. The centre of the nodules contain tubercle bacilli cells gather around the centre and usually the outer portion becomes fibrosed. Thus, blood vessels are compressed, nutrition of tubercle is impaired, and necrosis occurs at the centre. The area becomes walled off by fibritic tissue, and the centre gradually becomes soft and cheesy in consistency. This later process is known as "Caseation necrosis". This material may become calcified (calcium deposits) or it may liquify (liquification necrosis). The liquified material may be coughed up, leaving a cavity or hole in the parenchyma of the lung. This cavity or cavities are visible on chest X-ray films and results in the diagnosis of cavitary disease. The only X-ray evidence of TB infection is a calcified nodule known as "Ghon's tubercle". Ghon's tubercle is referred to as the "primary complex". When a tuberculosis lesion regresses and heals, the infection enters a latent period in which it may persist without producing a clinical illness. The infection may develop

into clinical disease if the persisting organism begins to multiply rapidly, or it may remain dormant. If the initial immune response is not adequate, control of the organisms is not maintained and clinical disease results. Certain individuals are at a higher risk for clinical disease including those who are immunosuppressed, e.g. HIV, cancer, person who received chemotherapy or cortico-steroid therapy or have diabetes mellitus. Dormant but viable organism persists for years. Reactivation of TB can occur if the host defense mechanisms become impaired.

In the early stages of TB, the person is usually free of symptoms. Many cases, if it is found that incidentally when routine chest X-rays are taken, especially in older adults. Systemic manifestation may initially consist of fatigue, malaise, anorexia, weight loss, low grade fever (especially in late afternoons) and night sweats. The weight loss may not be excessive until late in the disease and is often attributed to overwork or other factors. Irregular menses may also be present in premenopausal women.

A characteristic pulmonary manifestation is cough that becomes frequent and produce mucoid or macopurulent's sputum. Chest pain characterised as dull or tight may also be present. Hemoptysis is not a common finding and is usually associated with more advanced cases. Sometimes TB has more acute, sudden manifestation, the patient has high fever, chills, generalised of the like symptoms, pleuritic pain and a production of cough.

The complication of TB are miliary tuberculosis, pleural effusion, TB pneumonia, involvement of other organs, e.g. bone, kidney, brain, etc.

This will be diagnosed by taking prompt health history and physical examination. The diagnostic studies of TB include:

• Tubercular skin testing, montoux test.
• Chest X-rays.
• Bacteriological studies-sputum smear, sputum.
• WBC Serologic test by ELISA (enzyme-linked immunosorbent assay).
• CSF.

The common drugs used for management of tuberculosis are: i. Isoniazid (INH): Interferes with DNA metabolism and tubercle bacilli. It is bactericidal, penetrates all body tissues and fluids, including CSF. The side effects include peripheral nueritis, hepatotoxicity, hypersensitivity (skin rash, arthralgia, fever), Optic neuritis, vit B6 neuritis. INH metabolizes primarily by liver and excretion by kidneys, pyridoxine (vit B6) administration during high dose therapy as prophylactive measure, use as single prophylactic agent. For active TB in individuals whose PPD converts to positive, ability to cross blood-brain barrier. Avoid alcohol and antacids during therapy. Daily alcohol intake interferes with metabolism of isoniazed and increases risk of hepatitis, antacids containing alluminium hydroxide also interferes with absorption of INH. ii. Rifampicin has broad spectrum effects, inhibits RNA polymerase of tubercle bacillus. It is bactericidal, penetrates all body tissues, including CSF. It is most commonly used with INH, low incidence of side effects, suppression of effects of birth control pills, possible orange urine. The other side effects may develop are hepatitis, febrile reactions, thrombocytopenia (Rare) GI disturbance, peripheral neuropathy, hypersensitivity, hepatotoxicity increases when given with INH. During its therapy, urine, sweat, tears may turn orange temporarily decrease effectiveness of oral contraceptives, anticoagulants, corticosteroids, barbiturates, hypoglycemics and digitalis. iii. Ethambutal inhibits RNA synthesis and a bacteriostatic for the TB bacilli and does not penetrate all body fluids except CSF. The common side effects are skin rash, GI disturbance, malaise, peripheral neuritis, and optic neuritis. It has no significant reaction with other drugs. Should be given with food. Periodic checking of vision needed. It is most commonly used as substitute drug when toxicity occurs with Refampicin and INH. iv. Streptomycin inhibits protein synthesis and is bacteriocidal. Poor penetration into body tissues and CSF. The side effects of streptomycin and INH include (eighth cranial nerve damage

streptomycin vestibular or occular) damage often irreversible, nephrotoxicity and hypersensitivity. It should be used cautiously in older adults those with renal disease and pregnant women; must be given parenterally. During its use patient should be monitored monthly for kidney function, vestibular function with caloric stimulation test, and hearing with audiogram. v. Pyrazinamide is bacteriostatic or bacteriocidal depending on susceptibility of mycobacterium (exact mechanism not known). Usual side effects of fever, skin rash, hyperuricemia, jaundice (rare) hepatitis, arthrolgia, GI irritation. High rate of effectiveness when used with streptomycin or capreomycin. In addition, ethionamide, capromycine, kanamycin and para-amino salicylic acid (PAS), cycloserine (seromycin) and used as second line of drugs for TB treatment.

A problem with antituberculosis therapy is the length of time medication must be taken. In the past, 18 to 26 months was the usual period of time required for individuals to adhere to the medical regiment. Shorter courses of therapy ( 6 to 9 months) have been shown to be effective. Now three options for treatment are available. Regimen option for the initial treatment of tuberculosis include:

Option 1. Four drug regimen consisting of isoniazid, rifampicin, pyrazinamide and either ethambutol or streptomycin. Therapy may be given daily or 2-3 times weekly if DOT (directly observed therapy). Ethambutol or streptomycin may be discontinued if susceptibility to isoniazid or rifampicin is documented. Pyrazinamide should be discontinued after 8 weeks. The total duration of the therapy should be at least 6 months and at least 3 months after sputum culture converts to negative. Fixed dose combination of all these drugs are available to simplify therapy.

Option 2. Daily isoniazid, rifampicin, pyrazinamide and streptomycin or ethambutol for 2 weeks followed by DOT twice weekly administration of the same drugs for 6 weeks followed by rifampicin for 16 weeks.

Option 3. DOT 3 times/weekly administration of isoniazid, rifampicin, pyrazinamide, and ethambutol or streptomycin for 6 months.

For TB with HIV infection cases, option 1, 2, 3 can be used, but treatment regimens should continue for a total of 9 months and at least 6 months beyond culture conversion.

Medical therapy is the primary treatment of tuberculosis, but surgery may be used to remove residual pulmonary lesions and patients. The surgical procedures then are used include wedge resection, segmental resection, lobectomy, etc.

A well-balanced diet containing the essential food groups, with a vitamin supplement is recommended. Those who are poorly nourished or underweight may benefit from six small feedings of high-calorie, high protein foods daily rather than three meals.

The major nursing responsibility is to teach the patient about TB and how it is transmitted. Preventing contamination of air with tubercle bacilli is accomplished by treating the patient antituberculosis drugs and teaching the patient to cover the nose and mouth with tissues when sneezing and coughing. Advise the patient, he must take antituberculosis drugs as prescribed and drugs are always taken as combination of at least four drugs initially and drugs must be taken uninterruptedly.

To improve airway clearance, the patient is taught to sit upright in a chair or bed. If the patient is confined to bed at home, he or she may find it helpful to sit on the side of the bed with the feet on a chair. The patient may be taught to take two or three deep breaths, cover the mouth with tissues and then cough. Using this method when coughing decreases fatigue because it requires less expenditure of energy than does repeated ineffective coughs. Many patients can cough most effectively when the mouth is moist and sips of water or a warm beverage such as tea or coffee can be encouraged before coughing.

For patients with thick tenacious sputum, fluid intake is encouraged to thin the secretions and make them easier to expectorate. Water is considered by many experts to be the most effective sputum liquifying agent.

To reduce fear about the disease and what lifestyle changes it will require, patients are encouraged to ask questions about anything they do not understand or anything that concerns them. The nurse who sits while talking with the patients signals them he or she will take the time to listen to the patient. All questions should be answered as completely as possible, supplying information appropriate to the patient's educational

level and ability to comprehend what is being taught. Written materials with diagram and drawings that reinforce what is being taught are helpful. The materials are given to the patient for use later on.

Nurses and other health care workers need to know the protective measures they can use when caring for patients who have a positive TB smear or culture.

Bronchiectasis is a disorder characterised by permanent, abnormal or irreversible dilation of the bronchial tree or one or more large bronchi.

When infection attacks the bronchial lining, inflammation occurs, and an exudate forms. The progressive accumulation of secretions obstructs the bronchioles. The obstructed bronchioles then breakdown, and ciliated columnar epithelium is replaced by non-ciliated cuboidal epithelium and sometimes fibroitic tissue, resulting in localised areas of dilations or saccules. The pathologic changes result in dilation and destruction of the elastic and muscular structures of the bronchial wall.

There are two pathological types of bronchiectasis, i.e. saccular and cylindrical. Saccular bronchiectasis occurs mainly in large bronchi and is characterised by cavity-like dilations. The affected bronchi end in large sacs. Cylindrical bronchiectasis involve medium-sized bronchi that are mildly to moderately dilated. Fusiform bronchiectasis occurs mainly in large bronchi and is characterized by cavity-like dilations. The affected bronchi end in large sacs cylindrical bronchiectasis involves medium sized bronchi that are mildly to moderately dilated. Fusiform bronchiectasis a subtype of cylindrical tends to involve more 'pouching' of the bronchi. The explosive force of the bronchioles is diminished and they may remain filled with exudate. Only forceful coughing and postural drainage will empty them. Almost all forms of bronchiectasis are associated with bacterial infections and viral infections (adenovir, influenza).

The condition may develop so gradually that the person is unable to tell when the symptoms first began.

Signs and symptoms of bronchiectasis vary with the severity of the conditions and may include the following:

• Cyanosis
• Clubbing of fingers
• Find crackles and coarse Rhonchi
• Dull or flat sound over the areas of mucus plugs
• Increased vocal and tactile fermitus over the middle and lower lobes
• Decreased diaphragmatic excursion, and
• Paroxysms of coughing on rising in morning and when lying down.

• Severe coughing productive of copious amounts of purulent sputum
• Hemoptysis
• Dyspnea
• Fatigue and weakness
• Loss of appetite and weight loss.

The diagnostic studies used to diagnose bronchiectasis are chest X-ray, bronchography, sputum examination and CT scanning.

Treatment of bronchiectasis includes:

• Administration of antibiotics on the basis of sputum culture results.
• Administering of bronchodilator, mucolytic agents and expectorants.
• Postural drainage to assist in mobilizing secretions to larger airways where they can be coughed up.
• Bronchoscopy to remove thicker secretions.
• Maintaining good hydration to liquify secretion.
• Maintaining good general hygiene including oral hygiene may contribute to relief symptoms.
• Adequate rest, diet, exercise and diversional activities.
• Avoiding superimposed infections such as colds.
• Individual should reduce exposure to excessive air pollutants and irritants, avoid cigarette smoking and obtain pneumococcal and influenza vaccinations.

Surgical resection of the parts of the lungs, necessary when signs and symptoms of bronchiaectasis persists despite medical therapy. The goal of surgery is to preserve as much functional lung as possible. Therefore, segmentectomy or lobectomy is given priority.

Empyema is pus within a body cavity most often the pleural cavity. It usually occurs after pleural effusion secondary to other respiratory diseases such as pneumonia, lung abscess, TB and fungal infections of the lung and also after thoracic surgery or chest trauma.

The patient with a lung infection or chest injury may develop empyema and should be observed closely for the following signs and symptoms of empyema:

• Cough (usually nonproductive)
• Dyspnea
• Tachypnea
• Tachycardia
• Elevation of temperature
• Unilateral chest expansion
• Malaise
• Decreased appetite.

The diagnosis can usually be made from the signs and symptoms and the medical history, but it is confirmed by a chest X-ray film that demonstrates the presence of a pleural exudate. A thoracentesis is performed to obtain sample of the pus for culture and sensitivity studies and to relieve the patient's respiratory symptoms.

The aim of treatment of empyema is to obliterate the pleural space by draining the empyema cavity completely. The cavity can be drained in the following ways.

• Initial treatment is often daily thoracentesis with aspiration of the cavity and instillation of antibiotics into the pleural space. Oral or IV antibiotics may also be given.
• If the cavity cannot be evacuated within a few days and if the lung fails to re-expand to obliterate then space surgery is necessary. The types of surgery depends on the situation and may include:
• Closed chest drainage
• Rib resection
• Decortication and
• Thoracoplasty

Nursing depends on the type and effectiveness of the procedure and the patient's symptoms. Some patients require oxygen therapy. Bed rest and coughing and deep breathing exercises may be indicated to improve ventilations. In some cases, the patient will go through several treatments before the empyema in space is closed. This can be frustrating, and the patient can become very discouraged. A major nursing role is to support the patient and family during the various procedure.

Lung abscess is a pus-containing lesion of the lung parenchyma that gives rise to a cavity. The cavity is formed by necrosis of the lung tissue.

In many cases, the causes and pathogenesis of lung abscess are similar to those of pneumonia. The more common contributing factor to a lung abscess is aspiration of material into the lungs. Risk factors for aspiration include alcoholism, seizure disorder, drug overdose, general anaesthesia, and cerebrovascular accidents. Most of the lung abscesses are caused by infectious agents, i.e. Klebsiella, S. aureus, anaerobic bacilli. Lung abscess also can result from hematogenously spread lung infarct secondary to pulmonary embolus, malignant growth, TB and various fungus and parasitic diseases of the lung.

The areas of the lung most commonly affected are the atypical segments of the lower lobes and the posterior segments of the upper lobes. Fibrous tissues usually form around the abscess in an attempt to wall it off. The abscess may erode into the bronchial system, causing the production of foul smelling sputum. It may grow

towards the pleura and cause pleuritic pain. Multiple small abscesses can occur within the lung.

The onset of a lung abscess is usually insidious, especially if anaerobic organisms are the primary cause. A more acute onset occurs with aerobic organisms. The most common manifestation is cough-producing, purulent (often dark brown) that is foul-smelling and foul tasting. Hemoptysis is common especially at the time that an abscess ruptures into a bronchus. Other common manifestations are fever, chills, prostration, pleuritic pain, dyspnea, cough and weight loss. History may reveal a predisposing condition such as alcoholism, pneumonia or oral infections.

Physical examination of the lungs indicate the dullness to percussion and decreases breath sounds on auscultation over the segment of lung involved. There may be transmission of breath sounds to the periphery if the communicating bronchus becomes patent and drainage of the segment begins. Crackle may also be present. Oral examination often reveals dental caries, gingivitis and peridontal infection.

Complication can occur include chronic pulmonary abscess, haemorrhage from abscess erosion into blood vessels, brain abscess, bronchopleural fistula, and empyema.

Diagnosis is made on the basis of physical examination, chest X-ray, sputum culture and sensitivity. Prolonged administration of antibiotics ( 6 to 8 weeks). Penicillin is the choice antibiotics. Recently, clindamycin or metronidazole in combination with penicillin are used.

The patient should be taught how to cough effectively. Chest physiotherapy and postural drainages are helpful. Frequent mouth care (every 2 to 3 hours) is needed to relieve the foul smelling odor and taste from the sputum. Diluted hydrogen peroxide and mouthwash are often effective. Rest, good nutrition, adequate fluid intake are all supportive measures to facilitate recovery. If dentition is poor and dental hygiene is not adequate and the patient should be encouraged to obtain dental care.

Surgery is indicated but occasionally may be necessary if re-infection of a large cavity lesion occurs.

Occupational or environmental lung diseases result from inhaled dust or chemicals. The duration of exposure and the amount of inhalant have a major influence on whether the exposed individual will have lung damage. Another factor is the susceptibility of the host.

Many pulmonary diseases are believed to be caused by substances inhaled in the work place. Occupational lung disease are more common in:

• Blue-collar workers than white collar workers.
• Industrial areas than in rural areas.
• Small and medium-sized business than in larger industrial plants. In some instances it is debatable whether a person's lung disease is clearly occupation specific. This is true in cases of bronchitis, asthma, emphysema, or cancer, because all of these conditions can be caused or aggravated by several factors found in many different occupations and by non-occupational factors such as smoking and air pollution.

Occupational lung disease can be divided into several categories. The major ones are:

• The pneumoconiosis (black lung disease)
• Asbestos-related lung diseases
• Hypersensitivity diseases including occupational asthma allergic alveolitis and
• Byssinosis (brown lung disease).

The pathophysiology, clinical manifestation and prevention of some common occupational diseases are as follows: i. Pneumoconiosis also known as 'dust in the lungs' is called by inhalation and retention of dust particles. Examples of this condition are: Silicosis, asbestosis and Byssinosis.

• Silicosis caused if inhaled silica dust, most common form seen in miners, foundry workers, and others who inhaled relatively low concentration of dust for 10-20 years.

In this dust accumulation is tissue or tissue reaction with whorl-shaped nodules throughout lungs. In complicated silicosis there is progressive massive fibrosis throughout lungs decreased lung function and corpulmonale. In acute silicosis, there is inflammatory reaction within alveoli, diffuse fibrosis. Rapid progression to respiratory failure. The clinical manifestation will include, breathlessness, weakness, chest pain, productive cough with sputum, dies of corpulmonale and respiratory failure. The preventive measures include dust control and improved ventilation can reduce dust levels. Sand blasters in enclosed spaces can use special suits and breathing apparatus. The complicated progressive massive fibrosis shortens life-span. ii. Asbestos-related lung disease: Asbestos caused lung cancer, malignant mesothelioma of pleura and periosteum, cancer of the larynx, and certain gastrointestinal cancer, also cause asbestosis of fibrotic lung disease. Fibrosis caused by asbestos called asbestosis, asbestos fibers, accumulated around terminal bronchioles, surrounds fibers with iron rich tissue, forming asbestos body with characteristic picture on X-ray, more asbestos bodies as more fibers are inhaled, after 20-30 years of exposure fibrosis begins in lungs, interstitial fibrosis develops. Pleural plaques, which are calcified lesions develop on pleura. Dyspnea, basal crackles, and decreased vital capacity, are early manifestation. The complications include diffused interstitial pulmonary fibrosis. Lung cancer especially in cigarette smokers, mesothelioma (cancer affecting pleura and peritonial membrane). Treatment with radical pleurectomy and pneumonectomy survival only for 1-2 years. Preventive measures include enforcement for regulations governing mining milling and use of asbestos. Protective masks must be used when working with asbestos. iii. Hypersensitivity diseases fall into occupational category when can occur in bronchi, bronchioles or alveoli, coarse dust causes bronchial reactions, fine dust previous small airway and alveolar reactions.

• In occupational asthma, hypersensitivity reaction mediated by histamine bronchoconstriction and increased mucus production repeated attacks if cause unrecognised and asthma is untreated, may lead to permanent obstructive lung disease; asthmatic response that is well established can be provoked by other factors (i.e. house dust, cigarette smoke) and by fatigue, breathing cold air and coughing where wheezing is major symptom. It can be prevented by total elimination of antigen, desensitization not successful.
• In farmer's lung (hypersensitivity pneumonitis or allergic alveolitis), alveoli are inflamed, inundated by WBCs, sometimes filled with fluid, if exposure infrequent or level of dust low, symptoms are mild, and treatment not sought, chronic form develops over a period of time eventually fibrosis occurs, and fibrosis may be so well established that it cannot be arrested. Symptoms begin some hours after exposure to offending dust and include fatigue, shortness of breath, dry cough, fever, and chills. Symptoms may be severe enough to require emergency treatment and hospitalization; acute attacks treated with steroids, recovery may take 6 weeks and patient may have residual lung damage, real cure is permanent separation of patient and antigen. Preventive measures include properly dried and stored farm products (hay, straw, sugar cane) do not cause allergic alveolitis. Presumably fungi only grow in moist condition. iv. Byssinosis (Brown lung disease) is occupational disease. Occurs in textile workers; mainly in cotton workers but also afflict workers in flax and hemp industries; cause is found in bales of raw cotton. In this, chronic bronchitis and emphysema develop in time. Constriction of bronchioles in response to something in crude cotton. Symptoms of asthma and allergy persists long, there is exposure to cotton antigen. Clinical manifestations that develop are tightness in chest on returning to work after a weekend

away (Monday fever), strong relationship between amount of dust inhaled and symptoms. Persistent of symptom increases tightness of chest with chronic bronchitis and emphysema, person leaves industry as respiratory cripple. The preventive measures include-dust control measures, pretreating bales of cotton by washing with steam and other agents may inactivate causative agent, try to detect persons who are likely to become sensitized to cotton dust and keep them out of high risk areas.

Medical therapy of these patients depend on the patient's signs, symptoms and complications. The major role of nurses is to be knowledgeable about the cause and prevention of occupational lung diseases, so that appropriate information and teaching can be presented to community. The best approach to management is to try to prevent or decrease environmental and occupational risks. Well-designed effective ventilation system can reduce exposure to irritants, wearing mask is appropriate in some occupations. Cigarette smoking must be avoided.

Early diagnosis is essential if the disease process is to be halted. The best treatment is to decrease or stop exposure to the harmful agents. Some places of employment at which there is a known risk of lung disease may require periodic test.

X-rays and pulmonary function studies for exposed employees. There is no specific treatment for most environmental lung diseases. Treatment is directed towards symptomatic relief. If there is coexisted problem such as pneumonia, chronic bronchitis, emphysema, or asthma they are treated on providing nursing care accordingly.

Cancer of the lung may be either metastatic or primary. Metastatic tumours may follow malignancy anywhere in the body. Metastasis forms the colon and kidney are common. Metastasis to the lung may be discovered before the primary lesion is known, and sometimes locations of the primary lesion may be found only at autopsy.

Cigarette smoking as a chronic respiratory irritant is by far the major risk factor in the development of lung cancer. Heredity may play a role in both the tendency to smoke and the predisposition to develop lung cancer. Another possible risk factor is pre-existing pulmonary disease such as TB, pulmonary fibrosis, bronchiectasis and COPD.

The pathogenesis of primary lung cancer is not well understood. Usually cancers originate from the epithelium of the bronchus (bronchogenic). They grow slowly and it takes 8 to 10 years for a tumor to reach 1 cm in size, which is smallest detactable lesion on an X-ray. Lung cancer occurs primarily in the segmental bronchi or beyond and have a preference for the upperlobes of the lungs. Pathologic changes in the bronchial system show non-specific inflammatory changes with hypersecretions of mucus, desquamation of cells, reactive hyperplasia of the basal cells, and metaplasia of normal respiratory epithelium to stratified squamous cells. Lung cancers metastasize primarily by direct extension and via the blood circulation and the lymph system. The common sites for metastatic growth are the liver, brain, bones, scalene lymph nodes and adrenal glands.

Certain lung cancers cause the paraneoplastic syndrome, which is characterised by various manifestations caused by certain substances (e.g. hormones, enzymes and antigens) produced by the tumor cells. Small cell lung cancer most commonly is associated with it.

Lung cancer is clinically silent for most individuals for the majority of its course. The clinical manifestations of lung cancer are usually non-specific and appear late in the disease process. A patient's signs and symptoms depend on several factors including location of the lesion. Signs and symptoms of lesion in the bronchus and lung include:

• Approximately 10 per cent of patients are asymptomatic and cancer is identified on routine chest X-ray film.

• Approximately 75 per cent have a cough.

• Approximately 50 per cent have a haemoptysis.

• Shortness of breath and a unilateral wheeze are common. Peripheral lesions that perforate into pleural space shows extrapulmonary intrathoracic signs and symptoms. These include:

• Pain on inspiration

• Friction rub

• Pleural effusion

• Edema of face and neck when superior vena cava is involved

• Fatigue, and

• Clubbing fingers

Later manifestations include non-specific system and symptoms such as anorexia, fatigue, weight loss, nausea and vomiting. Hoarseness may be present as a result of involvement of the recurrent laryngeal nerve. Unilateral paralysis of the diaphragm, dysphagia and superior vena cava obstruction may occur because of the intrathoracic spread of the malignancy.

Diagnosis may be confirmed by taking accurately the-

• Health history and physical examination
• Chest X-ray to depict tumor
• Sputum in cytologic study-for examining bacteria and cancer cells
• Bronchioscopy
• CT scan
• MRI
• Positron emission tomography (PET)
• Spirometry (preoperative)
• Mediastinoscopy
• Pulmonary angiography
• Lung scan

Surgical resection is usually the only hope for cure in lung cancer. The types of thoracic surgery and indications for their use are as follows:

• Exploratory thoracotomy is performed to confirm suspected diagnosis of lung or chest disease, especially carcinoma; to obtain a biopsy; being replaced by non-invasive procedure (Thoracoscopy).
• Pneumonectomy is removal of a lung, bronchogenic carcinoma when lobectomy will not remove all of lesion, tuberculosis when other surgery will not remove all of diseased lung.
• Pneumonectomy is lung reduction surgery to reduce lung volume and decrease tension on respiratory muscle in persons with emphysema.
• Lobectomy is removal of one lobe of lung, bronchogenic carcinoma confined to a lobe, bronchiectasis, emphysematous blebs or bullae, lung abscess; fungal infections, benign tumors, and tuberculosis.
• Bilobectomy in removal of two lobes from right lungs, bronchogenic carcinoma when lobectomy will not remove all of disease.
• Sleeve lobectomy in the resection of main bronchus or distal trachea with reanastomosis to a distal uninvolved bronchus, bronchogenic carcinoma to preserve functional parenchyma.
• Segmental resection is known as segmentectomy, that is removal of one or more lung segments; bronchiectasis, lung abscess or cyst; metastatic carcinoma and tuberculosis.
• Wedge resection is a removal of pie-shaped section from surface of lung, well-circumscribed benign tumors, metastatic tumors or localised inflammatory disease, including TB.
• Decortication is removal of fibrinous peel from visceral pleura; chronic empyema.
• Thoracoplasty is removal of ribs, residual airspace after resectional surgery; chronic empyema space. Radiation therapy is used as curative approach in the individual who has resectable tumor but who is considered a poor surgical risk. It is also used as palliative procedure to reduce distressing symptoms such as cough, hemoptysis, bronchial obstruction, and superior vena cava syndrome.

Chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery in non-small cell lung carcinoma.

Biologic therapy used as adjuvant therapy. Phototherapy, i.e. laser surgery with use of the Nd:YAG also useful in some cases.

The best way to prevent lung cancer is to abstain from smoking. When it is confirmed, nurse has to assist in supporting the patient in all above stated procedures and take suitable nursing measures accordingly.

Preoperative teaching is essential for patients who are undergoing thoracic surgery. The goal of teaching is to prepare the patient for what he or she is expected to do postoperatively. The nurse who is caring for the patient is responsible for determining what the patient understands about the impending surgery and to be sure that preoperative teaching is completed. The points to be discussed in teaching include:

• Patient's knowledge of procedure
• Explanation of procedure is necessary, including intubation for anesthesia, site of incision and chest tube(s) and drainage system.
• Oxygen
• Blood administration and IV
• Pain medication, including PCA if used
• What the patient will be asked to do
• Coughing and deep breathing
• Arm exercise and
• Ambulation.
• Where patient will be taken after surgery.
• to recovery-how long
• to ICU-for how long
• Where family can wait during surgery.

The other routines of preoperative care of any surgery has to be followed.

The care of the patient after thoracic surgery centres on promoting ventilation, and re-expansion of the lung by maintaining a clear airway, maintaining the closed drainage system, promoting nutrition, monitoring the incision for bleeding and subcutaneous emphysema.

In most of the hospitals, the patient is taken from the recovery room to the ICU. The immediate postoperative nursing cares are as follows:

Oxygen is attached to the endotracheal tube in the immediate postoperative period. After extubation, humidified oxygen is given by cannula, usually at 6 L/minute. Oxygen mask should not be used to avoid cough and to rouse secretion.

The patient is usually attached to a cardiac monitor. A Swan- Ganz catheter and central venous pressure line are used for hemodynamic monitoring.

The patient is kept flat in bed or with head elevated slightly ( 20 degrees) until blood pressure is stabilised to preoperative levels. Once blood pressure is stabilised, the patient can usually breathe best in semiFowler's position with a pillow under the head and neck but not under the shoulders and back, because of the subscapular incision.

Vital signs are taken every 15 minutes until the patient is well recoverd from anesthesia, every hour until condition has stabilised, and then every 2 to 4 hours. Any deviation should be reported immediately to take suitable measures.

The patient should be assisted to cough as soon as conscious and extubated. If blood pressure is stable, the patient is assisted to sitting position, and the incision is supported anteriorly and posteriorly by the nurse's hands. Firm, even pressure over the incisions with the open palm of the hands is most effective method. The nurse's head should be behind the patient when the patient is coughing. The patient is encouraged to breathe deeply, exhale and then cough. Sips of fluid especially warm ones such as tea or coffee often facilitate coughing. Deep breathing or coughing keep the airway patent, prevent atelectasis and facilitate re-expansion of the lung. Patient is assisted every 2 to 4 hours around the clock. When a patient is unable to cough effectively tracheobronchial suctioning is performed.

Abdominal breathing exercises are a valuable adjunct to the care of the patient with chest surgery, because it improves ventilation without increasing pain, assist in coughing more effectively.

Medication for pain should be given as needed and may be required as often as every 3 to 4 hours during the first 48 to 72 hours. PCA and epidural catheters are widely used for pain medication management. Usually morphine is ordered for pain. If medication for pain fails intercostal nerve block may be performed.

Passive arm exercises are usually started in the evening of surgery. The purpose of pulling the patient's arm through range of motion is to prevent restriction of function.

The patient is encouraged to take fluids postoperatively and to progress to general diet as soon as it is tolerated. Fluid helps liquefy secretions and make them easier to expectorate. A diet adequate in protein and vitamins (especially vit C) facilitates wound healing.

The dressing is checked periodically for bleeding. Blood on the dressing is unusual and should be reported to the surgeon at once. The time and amount of blood are recorded in the patient's record. Air leak from the pleural space through the thoracotomy incision or around the chest tubes into the soft tissues indicates subcutaneous emphysema. The presence of air under the skin is readily detected and has been described as feeling like 'tissue paper' "rice krispies" under the skin.

All patients who have resectional surgery of the lung, except those having a pneumonectomy will require drainage of the pleural space by one or two chest tubes connected to closed drainage. Precautions to be observed with any type of closed drainage system are as follows:

• Monitor drainage system for tidaling (fluctuating) in one water seal chamber:
• Be sure the patient is not lying on the tubes.
• Check connections to be sure the chest tube system is intact.
• Ask patient to cough or change position to see if tidaling is resorted.
• Tidaling will stop when the lung is re-expanded.
• Never lift the closed drainage system above the level of the patient's chest, because this allows fluid to be pulled into the pleural space.
• Never clamp chest tubes without a written order from the surgeon because air (positive pressure) will be trapped in the pleural space, further collapsing the lung.
• A liter bottle of sterile water is kept at the bedside at all times. If the patient's chest drainage system cracks or breaks.
• Insert patiently chest tube into the bottle of sterile water
• Remove the cracked or broken system and
• Obtain new system and connect it to patient's chest tube as soon as possible.
• If the patient's tube is accidentally pulled out of the chest (rarely occurs)
• Apply gloves in accordance with body substance isolation policy
• Pinch skin opening together with fingers
• Apply occlusive dressing
• Cover dressing with overlapping pieces of 2inch tape
• Call surgeon immediately

Chest tubes are removed when there is no tidaling of fluid in the water-sealed chamber and when X-ray films confirm the full re-expansion of the lung.

Chest trauma is a major problem often seen in the casualty. Injury to the chest may affect the bony chest cage, pleura and lungs, diaphragm, or mediastinal contents.

Injury to the chest are broadly classified into two groups- blunt and penetrating. i. Blunt trauma or non-penetrating injuries damage the structures within the chest cavity without disrupting chest wall integrity. Blunt injury

occurs when the body is struck by a blunt object, such as steering wheel. The external injury may appear minor but the impact may cause severe, life-threatening internal injuries such as ruptured spleen.

• Blunt steering wheel injury to chest may lead to rib fracture, flail chest, pneumothorax, hemopneumothorax, cardiac contusion, pulmonary contusion, cardiac tamponade, great vessel tears.
• Shoulder harness seat belt injury may lead to fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion, pericardial contusion, cardiac temponade.
• Crush injury (e.g. heavy equipment, crushing thorax) leads to pneumothorax and hemopneumothorax, flail chest, great vessel tears and rupture, decreased blood returned with decreased cardiac output.
• Countrecoup trauma-a type of blunt trauma, is caused by the impact of parts of the body against other objects. Examples are many head injuries caused by countrecoup trauma. The causes of blunt injuries are, motor vehicle accident, pedestrian accident, fall, assault with blunt object, crush injury, and explosion. ii. Penetrating trauma or injuries disrupt chest wall integrity and result in alteration in intrathoracic pressures. It occurs when a foreign body impales or passes through the body tissue, e.g. gunshot wound, stabbing, with knife, gunshot, stick, arrow and other missiles. Gunshot or stab wound to chest may lead to open pneumothorax, tension pneumothorax, hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears. Emergency care of the patient with chest trauma requires an accurate assessment of respiratory, cardiovascular and surface finding which include:
• Respiratory
• Dyspnea, respiratory distress
• Cough with or without hemoptysis
• Cyanosis of the mouth, face, nail beds, mucous membrane
• Tracheal deviation
• Audible air escaping from the chest wound
• Decreased breath sounds on side of injury
• Decreased oxygen saturation, and
• Frothy secretions.
• Cardiovascular
• Rapid, thready pulse
• Decreased blood pressure
• Narrowed pulse pressure
• Asymmetric blood pressure value in arms
• Distended neck veins
• Muffled heart sounds
• Chest pain
• Crunching sounds synchronous with heart sounds
• Arrhythmias.
• Surface findings
• Bruising
• Abrasions
• Open chest wounds
• Asymmetric chest movement
• Subcutaneous emphysema.

The emergency care are:

• Ensure patient airway
• Administer high-flow $\mathrm{O}_{2}$ with non-rebreather mask
• Establish IV access with two large-bore catheters. Begin fluid resuscitation as appropriate
• Remove clothing to assess injury
• Cover sucking chest wound with non-porous dressing taped on three sides
• Stabilize impaled objects with bulky dressings. Do not remove
• Assess for other significant injuries and treat appropriately
• Stabilise flail rib segment with hand followed by application of large pieces of tape horizontal across the flail segment
• Place patient in a semi Fowler's position or position the patient on injured side if breathing is easier after Cervical spine injury has been ruled out. An ongoing monitoring will include:
• Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, respiratory status and urinary output
• Anticipate intubation for respiratory distress
• Release dressing if tension pneumothorax develops after sucking chest wound is covered.

Thorax injuries range from single rib fracture to the life threatening tears of aorta, vena cava, and other major vessels. The most coronary thoracic emergencies are as follows:

Rib fractures are the most common type of chest injury (Blunt injury), resulting from trauma ribs (4-9) 3rd to 10th are most commonly fractured because they are least protected by chest muscles. If the fractured rib is splintered or displaced, it may damage the pleura and lungs.

Ribs usually function at the point of maximum impact, but they may fracture at a site distant from impact. Rib fractures are caused by blows, crushing injuries, or strain caused by severe coughing or sneezing spells. When the rib is splintered or the fracture displaced, sharp fragments may penetrate the pleura and lungs, resulting in a hemothorax (blood in the pleural space) or pneumothorax (air in the pleural space) which are penetrating injuries.

• Pain at the site of injury, especially increasing on inspiration
• Localised tenderness and crepitus on palpation
• Splinting of chest and shallow breathing

Fractures are confirmed by chest X-ray. The main goal in treatment is to decrease pain so that patient can breathe adequately to promote good chest expansion. Intercostal nerve blocks with local anesthesia ( $1 \%$ procaine) may be used to provide pain relief and analgesics is given to relieve pain so that the patient can be encouraged to breathe more rapidly.

The patient is observed for splinting of the chest and shallow breathing to which could lead to atelectasis. To improve breathing, the patient is placed in a position of comfort. Most of the patients are able to breathe best in Fowler's or semi Fowler's positions.

The patient and family should be educated regarding:

• The patient should rest and do nothing strenuous for several days.
• The patient should take deep breath every hour.
• Narcotic drug therapy must be individualised and used with caution because these drugs can depress respiration.
• The Pain is not relieved if analgesic call physician.
• If shortness of breath, sudden sharp chest pain, coughing up blood occurs, rush to casualty part of hospital.

Flail chest results from multiple rib fractures and thereby causing instability of the chest wall.

When multiple ribs or the sternum is fractured in more than one places, a portion of the chest wall becomes separated from the chest cage, resulting in a flail chest. The chest wall cannot provide the bony structures necessary to maintain Bellows action and ventilation. The affected (flail) area will move paradoxically the intact portions of the chest during respiration. During inspiration the affected portion is sucked in, and during expiration it bulges out. This paradoxical chest movement prevents adequate ventilation of the lung in the injured area. The underlying lung may or may not have a serious injury. Associated pain and any lung injury give rise to loss of compliance, will contribute to an alteration in breathing pattern and lead to hypoxemia. And may also develop hypercapnia and respiratory acidosis due to increased work of breathing.

• Severe chest pain
• Paradoxical breathing (asymmetrical chest movement)
• Oscillation of mediastinum
• Increasing dyspnea
• Rapid shallow respiration
• Accessory muscle breathing
• Restlessness
• Decreased breath sounds on auscultation
• Cyanosis
• Anxiety related to difficult breathing.

• Stabilising the flail segment position endexpiratory pressure (PEEP) used with mechanical ventilation to improve oxygenation will maintain pressure in the lungs throughout the respiratory cycle.

• Provide supplemental oxygen: Monitor with pulse oximetry.

• Correct acid-base balance by mechanical ventilation

• Provide analgesic for pain control

• For severe pain, epidural anesthesia may be used

• Avoid fluid overload

• Patient should be confined to bed as he or she is on a ventilator.

A pneumothorax is a complete or partial collapse of a lung as a result of an accumulation of air in the pleural space. Pneumothorax may be closed or open.

The common form is:

• Spontaneous pneumothorax, which is caused by rupture of small blebs on the visceral pleural space. The cause of the bleb is unknown. This condition occurs most commonly in male cigarette smokers between 20-40 years of age. The other causes include:
• Injury to the lungs from mechanical ventilation
• Injury to the lungs from insertion of a subclavian catheter
• Perforation of esophagus
• Injury to the lungs from broken ribs
• Receptive blebs or bullae in a patient with COPD (e.g. asthma).

Small or slowly developing pneumothorax may produce no symptoms, but in large or rapidly developing pneumothorax results in:

• Sharp pain on respiration
• Increasing dyspnea
• Increasing restlessness
• Diaphoresis
• Hypotension
• Tachycardia
• Absence of chest movement in affected side
• Hyper resonance on affected side (topercussion). Management of closed pneumothorax will include:
• Observation on outpatient basis
• Giving supplemental oxygen
• Needle aspiration of air from pleural space, if present, insertion of chest catheter connected to a flutter valve or closed drainage system (suction or vented drainage).

Open pneumothorax occurs when air enters the pleural space through an opening in the chest wall. For example, gunshot or stab wound to chest in surgical thoracotomies. A penetrating chest wound is often referred to as a "sucking chest wound, because each time the person inspires, air is sucked into pleural space. In which, sucking sounds at wound site with respiration and tracheal deviation (trachea moves towards unaffected area during inspiration and returns towards midline) inspiration are the clinical manifestations.

This will be managed by occlusion of open wound and use other measures as in closed pneumothorax.

Tension pneumothorax may result from either in open or a closed pneumothorax. It occurs when air enters the pleural space on inspiration but cannot leave it on expiration. Although usually a result of a closed pneumothorax, a tension pneumothorax can be caused by a penetrating chest injury. The accumulated air builds up positive pressure in the chest cavity resulting in the following:

• Lung collapse on the affected side.

• Mediastinal shift towards the unaffected side.

• Compression of mediastinal contents (heart, great vessels) resulting in decreased cardiac output and decreased venous return. The clinical manifestation, tension pneumothorax will include:

• Severe dyspnea

• Agitation

• Trachea deviated from midline toward unaffected lung mediastinal shift

• Jugular venous distention

• Absence of chest movement on affected side

• Hypotension, tachycardia

• Breath sounds absent on affected side

• Hyper resonance on affected side

• Diminished heart sounds

• Shock

• Subcutaneous emphysema

• Ineffective ventilation.

Tension pneumothorax is a medical emergency because both the respiratory and circulatory systems are affected. If the tension of the pleural space is not relieved, the patient is likely to die from inadequate cardiac output or marked hypoxemia. Nurses are now being trained to insert large bore needle and chest tube into the chest walls to release the trapped air. Tension of pneumothorax usually occurs during mechanical ventilation or resuscitative efforts. Since it is the emergency defect in chest wall, covered with a sterile dressing, and insertion of chest tube connected to a flutter valve or closed drainage system.

Hemothorax is an accumulation of blood in the intrapleural space. It is frequently found in association with open pneumothorax. It may be due to chest trauma, lung malignancy, complication of anticoagulative therapy, pulmonary embolus, and tearing of pleural adhesions. The clinical manifestations are: If it is small, mild tachycardia, and dyspnea, air present. If it is large, respiratory distress may be present, which include shallow, rapid, respiration, dyspnea and air hunger. Chest pain or cough with or without hemoptysis. No breath sounds heard on auscultation.

If tension pneumothorax develops, feature of these also develop as a clinical manifestation.

Treatment of hemopneumothorax depends on air severity of the pneumothorax and the nature of the underlying disease. An emergency management will include chest insertion, auto-transfusion of collected blood, treatment of hypovolemia as necessary. Repeated spontaneous pneumothorax may need to be treated surgically by a partial pleurectomy, stapling or laser pleurodesis to promote adherence of the pleurae to one another. The injection of doxycycline (dry) an irritating agent can be used for pleurodesis.

Nursing intervention for closed, tension and open pneumothorax are as follows:

• Closed pneumothorax patient if he or she admitted performing the following:
• Place the patient in semi-Fowler's position
• Administer oxygen
• Obtain thoracentesis tray and closed drainage equipment. For outpatients or for patients after chest tube removal, instruct the patient to:
• Report any increased dyspnea to physician
• Avoid strenous exercises or activity that increases rate and depth of breathing
• Avoid holding breath
• Follow physician's instructions about resuming normal activity.
• Tension pneumothorax is life-threatening event; imperative that intervention be carried immediately to relieve increased intrapleural pressure; intervention same as those listed CP and performed the following:
• Monitor vital signs frequently
• Observe for cardiac dysrhythmias
• Palpate for subcutaneous emphysema in upper chest and neck
• Use same discharge instruction as in CP (above).
• Open pneumothorax performed the following:
• Occlude wound on the non-porous covering
• Same intervention as CP (closed pneumothorax), and
• Same discharge instruction as CP.

The pleural space lies between the lung and chest wall and normally contains a very thin layer fluid. Pleural effusion is a collection of fluid in the pleural space. It is not a disease but rather a sign of a serious disease. Pleural effusion is frequently classified as transudative or exudative according to whether the protein content of the effusion is low or high, respectively. A transudate occurs primarily in noninflammatory conditions and is an accumulation of protein-poor, cell-poor fluid. Transudtive pleural effusions (also called hydrothoraces) are caused by (1) increased hydrostatic pressure found in heart failure (HF), which is the most common cause of pleural effusion, or (2) decreased oncotic pressure (from hypoalbuminemia) found in chronic liver or renal disease. In these situations, fluid

movement is facilitated out of the capillaries and into the pleural space.

An exudative effusion is an accumulation of fluid and cells in an area of inflammation. An exudative pleural effusion results from increased capillary permeability characteristic of the inflammatory reaction. This type of effusion occurs secondary to conditions such as pulmonary malignancies, pulmonary infections, pulmonary embolization, and GI disease (e.g., pancreatic disease, esophageal perforation).

The type of pleural effusion can be determined by a sample of pleural fluid obtained via thoracentesis (a procedure done to remove fluid from the pleural space). Exudates have a high protein content, and the fluid is generally dark yellow or amber. Transudates have a low protein content or contain no protein, and the fluid is clear or pale yellow. The fluid can also be analyzed for RBCs and WBCs, malignant cells, bacteria and glucose.

An empyema is a pleural effusion that contains pus. It is caused by conditions such as pneumonia, TB, lung abscess, and infection of surgical wounds of the chest. A complication of empyema is fibrothorax, in which there is fibrous fusion of the visceral and parietal pleurae.

Common clinical manifestations of pleural effusion are progressive dyspnea and decreased movement of the chest wall on the affected side. There may be pleuritic pain from the underlying disease. Physical examination of the chest will indicate dullness to percussion and absent or decreased breath sounds over the affected area. The chest x-ray will indicate an abnormality if the effusion is greater than 250 ml . Manifestations of empyema include the manifestations of pleural effusion, as well as fever, night sweats, cough, and weight loss. A thoracentesis reveals an exudates containing thick, purulent material.

If the cause of the pleural effusion is not known, a diagnostic thoracentesis is needed to obtain pleural fluid for analysis. If the degree of pleural effusion is severe enough to impair breathing, a therapeutic thoracentesis is done to improve breathing and to remove fluid for analysis.

A thoracentesis is performed by having the patient sit on the edge of a bed and lean forward over a bedside table. The puncture site is determined by chest X-ray, and percussion of the chest is used to assess the maximum degree of dullness. The skin is cleaned with an antiseptic solution and anesthetized locally. The thoracentesis needle is inserted into the intercostal space. Fluid can be aspirated with a syringe, or tubing can be connected to allow fluid to drain into a sterile collecting bottle. After the fluid is removed, the needle is withdrawn, and a bandage is applied over the insertion site. Usually only 1000 to 1200 ml of pleural fluid are removed at one time. Because high volumes are removed, rapid removal can result in hypotension, hypoxemia, or pulmonary edema. A follow-up chest X-ray should be done to detect a possible pneumothorax that could have been induced by perforation of the visceral pleura. During and after the procedure, vital signs and pulse oximetry are monitored, and the patient should be observed for any manifestations of respiratory distress.

The main goal of management of pleural effusions is to treat the underlying cause. For example, adequate treatment of HF with diuretics an sodium restriction will result in decreased pleural effusions. The treatment of pleural effusions secondary to malignant disease represents a more difficult problem. These types of pleural effusions are frequently recurrent and accumulate quickly after thoracentesis. Chemical pleurodesis may be used to sclerose the pleural space and prevent reaccumulation of effusion fluid. Although doxycyline (Vibramycin) and bleomycin (Blenoxane) have been used for sclerosing with good results, talc appears to be the most effective agent for pleurodesis. Thoracoscopy can be used to perform talc pleurodesis after inspection of the pleural space. After instillation of the sclerosing agent, patients may be instructed to rotate their positions to spread the agent uniformly throughout the pleural space. The decision to rotate the patient from side to side to back depends on physician preference and the patients ability to tolerate turning. Chest tubes are left in place after pleurodesis until fluid drainage is less than $150 \mathrm{ml} /$ day and no air leaks are noted. A more rapid completion of

the pleurodesis procedure, in less than 24 hours, is reported in the literature with good results, and this limited admission for symptomatic malignant effusions may become more frequent.

Treatment of empyema is generally with chest tube drainage. Appropriate antibiotic therapy is also needed to eradicate the causative organism. A condition called trapped lung can occur with effusions and empyemas. This is a fibrous peel around the pleura that can cause pulmonary restriction. A decortication surgical procedure to remove the pleural peel may need to be performed.

The other conditions of lungs briefed here as pleurisy and atelectasis.

Pleurisy (pleuritis) is an inflammation of the pleura. The most common causes are pneumonia, TB, chest trauma, pulmonary infarctions, and neoplasms. The inflammation usually subsides with adequate treatment of the primary disease. The pain of pleurisy is typically abrupt and sharp in onset and is aggravated by inspiration. The patients breathing is shallow and rapid to avoid unnecessary movement of the pleura and chest wall. A pleural friction rub may occur, which is the sound over areas where inflamed visceral pleura and parietal pleura rub over one another during inspiration. This sound is usually loudest at peak inspiration but can be heard during exhalation as well.

Treatment of pleurisy is aimed at treating the underlying disease and providing pain relief. Taking analgesics and lying on or splinting the affected side may provide some relief. The patient should be taught to splint the rib cage when coughing. Intercostal nerve blocks may be done if the pain is severe.

Atelectasis is a condition of the lungs characterized by collapsed, airless alveoli. The most common cause of atelectasis is airway obstruction that results from retained exudates and secretions. This is frequently observed in the postoperative patient. Normally the pores of Kohn provide for collateral passage of air from one alveolus to another. Deep inspiration is necessary to open the pores effectively. For this reason, deep-breathing exercises are important in preventing atelectasis in the high-risk patient (e.g., postoperative, immobilized patient).

Pulmonary embolism (PE) is the blockage of pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue. The word embolus derived from a Greek word meaning "plug" or "stopper". A pulmonary embolus consists of material that gains access to the venous system and then to the pulmonary circulation. The material eventually reaches a section of the pulmonary arterial vessels, where it lodges, thus obstructing perfusion.

Most pulmonary emboli arise from thrombi in the deep veins of the legs. Other sites of origin include the right side of the heart (especially with a trial fibrillation), the upper extremities (rare), and the pelvic veins (especially after surgery or childbirth). Lethal pulmonary emboli most commonly originate in the femoral or iliac veins. Emboli are mobile clots that generally do not stop moving until they lodge at a narrowed part of the circulatory system. The lungs are an ideal location for emboli to lodge because of their extensive arterial and capillary network. The lower lobes are most frequently affected because they have a higher blood flow than the other lobes.

Thrombi in the deep veins can dislodge spontaneously. However, a more common mechanism is jarring of the thrombus by mechanical forces, such as sudden standing, and by changes in the rate of blood flow, such as those that occur with the valsalva maneuver. The majority of patients with PE due to deep vein thrombosis (DVT) have no leg symptoms at the time of diagnosis.

In addition to dislodged thrombi, less common causes of PE include fat emboli (from fractured long bones), air emboli (from improperly administered IV therapy), bacterial vegetations, amniotic fluid, and tumors. Tumor emboli may originate from primary or metastatic malignancies.

The most common risk factors for PE are immobilization, surgery within the last 3 months, stroke, history of DVT, and malignancy. The Nurse's Health Study reported an increased risk of PE in women associated with obesity, heavy cigarette smoking, and hypertension. More than $95 \%$ of pulmonary emboli arise from thrombi in the deep veins of the lower extremity. Generally the DVTs that

are below the knee have not been considered a risk factor for PE since they rarely migrate to the pulmonary circulation without first extending above the knee. Upper extremity DVT occasionally occurs in the presence of central venous catheters or cardiac pacing wires. These cases may resolve with removal of the catheter. The highest rate of DVT is seen in spinal cord injury patients.

The signs and symptoms of PE are generally subtle and nonspecific, making diagnosis difficult. The classic triad of dyspnea, chest pain, and hemoptysis occurs in only about $20 \%$ of patients. The most common manifestations of PE are anxiety and the sudden onset of unexplained dyspnea, tachypnea, or tachycardia. A mild to moderate hypoxemia with a low $\mathrm{PaCO}_{2}$ is a common finding. Other manifestations are cough, pleuritic chest pain, hemoptysis, crackles, fever, accentuation of the pulmonic heart sound, and sudden change in mental status as a result of hypoxemia.

Massive emboli may produce sudden collapse of the patient with shock, pallor, severe dyspnea, hypoxemia, and crushing chest pain. However, some patients with massive PE do not have pain. The pulse is rapid and weak, the BP is low, and ECG indicates right ventricular strain. When rapid obstruction of $50 \%$ or more of the pulmonary vascular bed occurs, acute cor pulmonale may result because the right ventricle can no longer pump blood into the lungs. The mortality rate of persons with massive PE and shock is approximately $33 \%$.

Medium sized emboli often cause pleuritic chest pain, dyspnea, slight fever, and a productive cough with blood streaked sputum. A physical examination may reveal tachycardia and a pleural friction rub. Small emboli frequently are undetected or produce vague, transient symptoms. The exception to this is the patient with underlying cardiopulmonary disease, in whom even small- or medium-sized emboli may result in severe cardiopulmonary compromise. However, repeated small emboli gradually cause a reduction in the capillary bed and eventual pulmonary hypertension. An ECG and chest X-ray may indicate right ventricular hypertrophy secondary to pulmonary hypertension.

Pulmonary infarction (death of lung tissue) is most likely when the following factors are present: (1) occlusion of a large or medium-sized pulmonary vessel ( $>2 \mathrm{~mm}$ in diameter), (2) insufficient collateral blood flow from the bronchial circulation, or (3) preexisting lung disease. Infarction results in alveolar necrosis and hemorrhage. Occasionally the infracted tissue becomes infected, and an abscess may develop. Concomitant pleural effusion is frequently found.

Pulmonary hypertension occurs when more than $50 \%$ of the area of the normal pulmonary bed is compromised. Pulmonary hypertension also results from hypoxemia. As a single event, an embolus does not cause pulmonary hypertension unless it is massive. However, recurrent small to medium sized emboli may result in chronic pulmonary hypertension. Pulmonary hypertension eventually results in dilation and hypertrophy of the right ventricle. Depending on the degree of pulmonary hypertension and its rate of development, outcomes can vary, with some patients dying within months of the diagnosis and others living for decades.

A ventilation perfusion lung scan is the most frequently used test to aid in the diagnosis of PE. The lung scan has two components and is most accurate when both are performed:

1. Perfusion scanning involves IV injection of a radioisotope. A scanning device detects the adequacy of the pulmonary circulation
2. Ventilation scanning involves inhalation of a radioactive gas such as xenon. Scanning reflects the distribution of gas through the lung. The ventilation component requires the cooperation of the patient and may be impossible to perform in the critically ill patient, particularly if the patient is intubated. $D$-dimer testing may be recommended when a PE is initially suspected. D-dimer is a degradation product rarely found in healthy individuals. However, levels of D-dimer are elevated in any condition involving degradation of fibrin (infection, cancer, surgery, heart failure). They are elevated 8 times higher in venous thromboembolism. When D-dimer levels are normal ( $<250 \mathrm{mcg} / \mathrm{L}$ ), it is highly unlikely that the patient has

a PE. Thus a normal or near normal D-dimer level can rule out a PE. In the event that the D-dimer levels are elevated, a noninvasive venous study is indicated to look for a DVT as the likely source of a PE. If a DVT is located by venous ultrasound, the index of suspicion for PE is very high and anticoagulant treatment should be initiated immediately. Patients with an elevated Ddimer level but normal venous ultrasound need an elevated D-dimer level but normal venous ultrasound need a lung scan or spiral CT scan.

If the lung scan is inconclusive, pulmonary angiography is recommended. Pulmonary angiography is an invasive procedure that involves the insertion of a catheter through the antecubital or femoral vein, advancement to the pulmonary artery, and injection of contrast medium. This allows visualization of the pulmonary of contrast medium. This allows visualization of the pulmonary vascular system and location of the embolus.

The use of computed tomography (CT) has revolutionized the diagnosis of PE. A spiral (or helical) CT scan, a noninvasive diagnostic test, may also be used to diagnose PE. Conventional CT scans rotate a frame 360 degrees in one direction, stop, make an image (called a slice), and then spin back in the opposite direction to make another slice after again stopping. The spiral CT scan is able to continuously rotate while obtaining slices and does not have to start and stop between each slice. This allows visualization of entire anatomic regions such as the lungs. The data can be computer reconstructed to allow for a threedimensional picture of the area being imaged and assist in emboli visualization.

ABG analysis is important, but not diagnostic. The $\mathrm{PaO}_{2}$ is low because of inadequate oxygenations secondary to an occluded pulmonary vasculature. The $\mathrm{PaCO}_{2}$ is usually low because of hyperventilation. The pH remains normal unless respiratory alkalosis develops as a result of prolonged hyperventilation or to compensate for lactic acidosis caused by shock. Abnormal findings are usually reported on the chest X-ray (atelectasis, pleural effusion) and the ECG (ST segment and T wave changes), but they are not diagnostic for PE. Serum troponin levels are elevated in 30 to $50 \%$ of patients with PE, and, although not diagnostic, they are predictive of an adverse prognosis. Serum b-type natriuretic peptide (BNP) levels, while not diagnostic, may be helpful in identifying the severity of the clinical course.

When the diagnosis of PE has been made, treatment should be instituted immediately. The objectives of treatment are to (1) prevent further growth or multiplication of thrombi in the lower extremities, (2) prevent embolization from the upper or lower extremities to the pulmonary vascular system, and (3) provide cardiopulmonary support if indicated.

Conservative therapy: Supportive therapy for the patients cardiopulmonary status varies according to the severity of the PE. The administration of supplemental $\mathrm{O}_{2}$ by mask or cannula may be adequate for some patients. Oxygen is given in a concentration determined by ABG analysis. In some situations, endotracheal intubation and mechanical ventilation may be needed to maintain adequate oxygenation. Respiratory measures such as turning, coughing, and deep breathing are necessary to prevent or treat atelectasis. If symptoms of shock are present, vasopressor agents may be necessary to support the systemic circulation. If heart failure is present, diuretics are used. Pain resulting from pleural irritation or reduced coronary blood flow is treated with opioids, usually morphine.

Drug therapy: Properly managed anticoagulant therapy is effective in the treatment of many patients with PE. Although unfractionated heparin has been traditionally used for PE, low-molecular-weight heparin (e.g., enoxaparin [Levenox]) is becoming more commonly used in the treatment of PE. Warfarin (Coumadin) should be initiated within the first 24 hours and is typically administered for 3 to 6 months. Factor Xa inhibitors and direct thrombin inhibitors are also being used in the treatment of PE.

The dosage of heparin is adjusted according to the activated partial thromboplastin time (apt), while warfarin dose is determined by the international normalized ration (INR). Frequent changes and titrations of heparin doses are needed initially in order to obtain a therapeutic apt level. The heparin works to prevent future clots, but does not dissolve existing clots. Anticoagulant therapy may be contraindicated if

the patient has blood dyscrasias, hepatic dysfunction causing alteration in the clotting mechanism, injury to the intestine, overt bleeding, a history of hemorrhage stroke, or neurologic conditions.

Fibrinolytic agents, such as tissue plasminogen activator (tPA) or alteplase (Activase), dissolve the pulmonary embolus and the source of the thrombus in the pelvis or deep leg veins, thereby decreasing the likelihood of recurrent emboli. Indications for thrombolytic therapy in PE include hemodynamic instability and right ventricular dysfunction.

Surgical therapy: If the degree of pulmonary arterial obstruction is severe and the patient does not respond to conservative therapy, an immediate embolectomy may be indicated. Pulmonary embolectomy, a rare procedure, has a $50 \%$ mortality rate. Preoperative pulmonary angiography is necessary to identify and locate the site of the embolus. When a pulmonary embolectomy is performed, the patient also has placement of a vena cava filter.

To prevent further pulmonary embolization, an inferior vena cava (IVC) filter may be warranted. This device prevents migration of large clots into the pulmonary system, is easily and safely placed percutaneously, is biocompatible, and does not require the patient be anticoagulated. It can be used for patients who have an absolute contraindication to anticoagulant therapy. In addition, it may be used as a prophylactic measure for patients at high risk of PE (e.g., those with spinal cord injury or cor pulmonale). The complications associated with this device are rare and include misplacement, migration, and perforation. The spinal cord injury patient with an IVC filter cannot have assisted cough ("quad cough") to mobilize secretions since the quad cough procedure can displace the filter.

Nursing measures aimed at prevention of PE parallel those for prophylaxis of deep vein thrombosis. Acute intervention: The prognosis of a patient with PE is good if therapy is promptly instituted. The patient should be kept on bed rest in a semi-Fowler's position to facilitate breathing. An IV line should be maintained for medications and fluid therapy. The nurse should know the side effects of medications and observe for them. Oxygen therapy should be administered as ordered. Careful monitoring of vital signs, cardiac dysrhythmia monitoring, pulse oximetry, ABGs, and lung sounds is critical to assess the patients status. Laboratory results are monitored to assure normal ranges of aPPT and INR. Nursing care includes assessing for the complications of anticoagulant therapy (e.g., bleeding, hematomas, bruising) and PE (e.g., atelectasis, pneumonia). The nursing care plan includes interventions related to immobility and fall precautions.

The patient is usually anxious because of pain, sense of doom, inability to breathe, and fear of death. The nurse carefully explains the situation and provide emotional support and reassurance to help relieve the patients anxiety.

The patient affected by thromboembolic processes may require psychologic and emotional support. In addition to the thromboembolic problems, the patient may have an underlying chronic illness requiring longterm treatment. To provide supportive therapy, the nurse must understand and differentiate between the various problems caused by the underlying disease and those related to thromboembolic disease. Patient teaching regarding long-term anticoagulant therapy is critical. The anticoagulant therapy continues for at least 3 to 6 months; patients with recurrent emboli are treated indefinitely. Warfairn blood levels are initially drawn monthly, and patients may have follow-up appointments at a nurse-managed anticoagulation clinic to monitor their medication and adjust dosages.

Long term management is similar to that for the patient with DVT. Discharge planning is aimed at limiting progression of the condition and preventing complications and recurrence. The nurse must reinforce the need for the patient to return to the health care provider for regular follow-up examination.

Pulmonary hypertension is elevated pressures resulting from an increase in pulmonary vascular resistance to blood flow. The disease commonly presents with shortness of breath and fatigue. Pulmonary hypertension can occur as a primary disease (primary pulmonary hypertension) or as a secondary complication of a respiratory, cardiac, autoimmune, hepatic,

or connective tissue disorder (secondary pulmonary hypertension).

Primary pulmonary hypertension (PPH) is a severe and progressive disease. PPH is characterized by mean pulmonary arterial pressure greater than 30 mmHg with exercise in the absence of a demonstrable cause. Until the last decade, this disorder was rapidly progressive with right-sided heart failure and death. The median survival if untreated was 2.8 years. Epoprostenol (Flolan) therapy, introduced in the 1990s, greatly survival rates. Unfortunately, the disease remains incurable despite these advances.

The exact etiology of PPH is unknown. It is rare and potentially fatal disease. PPH has been linked to the use of fenfluramine in the drug Fen-Phen, which was used as an appetite suppressant to treat obesity. The drug was withdrawn from the market in 1996. PPH affects more women than men; the mean age at diagnosis is 36 years old. It may have a genetic component as the incidence is higher in families.

Normally the pulmonary circulation is characterized by low resistance and low pressure. In pulmonary hypertension, the pulmonary pressures are elevated. Until recently the pathophysiology of PPH was poorly understood. Recently it was discovered that a key mechanism involved in PPH is a deficient release of vasodilator mediators from the pulmonary epithelium, with a resultant cascade of injury. Vasoconstriction, remodeling of the walls of the pulmonary vessels, and thrombosis in situ are the three elements that combine to cause the increased vascular resistance. The remodeling process is a complex set of events involving endothelial cell injury that results in intimal/medial wall thickening.

Classic symptoms of pulmonary hypertension are dyspnea on exertion and fatigue. Exertional chest pain, dizziness and exertional syncope are other symptoms.

These symptoms are related to the inability of cardiac output to increase in response to increased oxygen demand. Eventually, as the disease progresses, dyspnea occurs at rest. Pulmonary hypertension increases the workload of the right ventricle and causes right ventricular hypertrophy (a condition called cor pulmonale) and eventually heart failure. A chest X-ray generally shows enlarged central pulmonary arteries and clear lung fields. An enlarged right heart may be seen. Echocardiogram usually reveals right ventricular hypertrophy. The mean time between onset of symptoms and the diagnosis is 2 years. By the time patients become symptomatic, the disease is already in the advanced stages and the pulmonary artery pressure is 2 to 3 times normal.

PPH is a diagnosis of exclusion. All other conditions must be ruled out. Diagnostic evaluation includes ECG, chest X-ray, pulmonary function tests, echocardiogram, and spiral CT. Cardiac catheterization is done to measure pulmonary artery pressure, cardiac output, and left ventricular filling pressure. Early recognition of pulmonary hypertension is essential to interrupt the vicious cycle responsible for the progression of the disease.

Although there is no cure of PPH, treatment can reliever symptoms, increase quality of life, and prolong life. Diuretic therapy relieves dyspnea and peripheral edema and may be useful in reducing right ventricular volume overload. Anticoagulation therapy is recommended for patients with severe pulmonary hypertension to prevent in situ thrombus formation and venous thrombosis. Warfarin is given to keep the INR in the 2 to 3 range. Hypoxia is a potent pulmonary vasoconstrictor, and use of low-flow oxygen provides symptomatic relief. The goal is to keep oxygen saturation at $\geq 90 \%$.

Vasodilator therapy is used to reduce right ventricular overload by dilating pulmonary vessels and reversing remodeling. Some patients with pulmonary hypertension can be effectively managed with calcium channel blocker therapy, such as sustained-release nifedipine (Procardia) or diltiazem (Cardizem).

Epoprostenol (Flolan) has revolutionized the management of PPH. It is a prostacyclin that promotes pulmonary vasodilation and reduces pulmonary vascular resistance. Continuous epoprostenol has been shown to result in significant improvement in clinical symptoms and long-term survival. It is now the treatment of choice for selected patients who are unresponsive to calcium channel blockers. Its administration requires the placement of an indwelling central line catheter and continuous infusion pump. The patient and the family must be trained to use the portable intravenous infusion pump, mix medications, manage the central line, and monitor for complication. The half-life of the drug is less than 6 minutes. If the central line is disrupted, stopped, or dislodged for any reason, clinical deterioration from abrupt withdrawal of epoprostenol can occur. This is a serious event with potential rebound pulmonary hypertension and clinical deterioration developing within minutes. The patient will have signs and symptoms of right sided heart failure, including dyspnea, cyanosis, cough, syncope, and weakness. If the patient loses significant weight, the dosage, which is weight based, may become excessive. Symptoms of over-dose include flushing, hypotension, and tachycardia. The major problems have been infectious related to vascular access and broken central lines.

Epoprostenol has been successful in improving the quality of life of patients with PPH. The drug was developed as a bridge to lung transplantation but is now a standard of care. Although the patient and family teaching is extensive, the patient on continuous epoprostenol therapy can be successfully managed with an interdisciplinary health care team.

Treprostinil (Remodulin), a prostacyclin, is used a continuous subcutaneous injection. It causes vasodilation of the pulmonary arterial system and inhibits platelet aggregation. The subcutaneous route had drawbacks, including needles that could dislodge and infusion site pain and reactions. The drug has recently been approved for continuous intravenous use. This drug is stable at room temperature and has a longer half-life than epoprostenol. It may be a reasonable alternative to epoprostenol for some patients.

Bosentan (Tracleer), a form of prostacyclin, is the only oral vasodilator currently approved for the treatment of pulmonary hypertension. It is an active endothelin receptor antagonist and works by blocking the hormone endothelin, which causes blood vessels to constrict. Monthly liver function tests are needed since there is a risk of hepatotoxicity. Sildenafil (Revatio) is an oral phosphodies-terase inhibitor that prolongs the vasodilatory effect of nitric oxide and appears to be as effective in decreasing pulmonary vascular resistance. It should not be taken by patients using nitrates because severe hypotension may develop. Iloprost (Ventavis) is inhaled form of prostacyclin in an aerosolized preparation. It is taken 6 to 9 times a day using a disk inserted into a nebulizer. Because of the risk of orthostatic hypotension, iloprost should not be taken by patients with low systolic blood pressure ( $<85 \mathrm{~mm} \mathrm{Hg}$ ). Beraprost (an oral formulation of prostacyclin) is undergoing clinical trials for the treatment of early stage pulmonary hypertension.

Surgical interventions for pulmonary hypertension include atrial septostomy (AS), pulmonary thromboendarterectomy (PTPE), and lung transplantation. AS involves the creation of an intra-atrial right to left shunt to decompress the right ventricle. It is indicated for a select group of patients awaiting lung transplantation. PTE may provide a potential cure for those patients suffering from chronic thromboembolic pulmonary hypertension. It is only recommended for patients with operable sites where the emboli can be surgically removed by embolectomy.

Lung transplantation has been the mainstay of treatment for pulmonary hypertension for those patients who do not respond to drug therapy and progress to severe right sided heart failure. Recurrence of the disease has not been reported in individuals, who have undergone transplantation. A patient education and support website for pulmonary hypertension is located.

Secondary pulmonary hypertension (SPH) occurs when a primary disease causes a chronic increase in pulmonary artery pressures. Secondary pulmonary hypertension can develop as a result of parenchymal lung disease, left ventricular dysfunction, intracardiac shunts, chronic pulmonary thromboembolism, or systemic connective tissue disease. The specific

primary disease pathology can result in anatomic or vascular changes causing the pulmonary hypertension. Anatomic changes causing the increased pulmonary vascular resistance include (1) loss of capillaries as a result of alveolar wall damage (e.g., COPD), (2) stiffening of the pulmonary vasculature (e.g., pulmonary fibrosis connective tissue disorders), and (3) obstruction of blood flow (chronic emboli).

Vasomotor increases in pulmonary vascular resistance are found in conditions characterized by alveolar hypoxia. Hypoxia causes localized vasoconstriction and shunting of blood away from poorly ventilated alveoli. Alveolar hypoxia can be caused by a wide variety of conditions. It is possible to have a combination of both anatomic changes and vasomotor constriction. This is found in the patient with long-standing chronic bronchitis who has chronic hypoxia in addition to loss of lung tissue.

The symptoms can reflect the underlying disease, but some are directly attributable to SPH, including dyspnea, fatigue, lethargy and chest pain. The initial physical findings can include right ventricular hypertrophy and signs of right ventricular failure (increased pulmonic heart sound, right sided fourth heart sound, peripheral edema, hepatomegaly). Diagnosis of SPH is similar to that of PPH. Treatment of SPH consists mainly of treating the underlying primary disorder. When irreversible pulmonary vascular damage has occurred, therapies used for PPH are initiated. The efficacy of treatment for pulmonary hypertension has been primarily evaluated for PPH, and there are limited data on the effectiveness of these therapies for SPH. Epoprostenol is used in the management of SPH. More studies are ongoing into effective therapies for SPH.

Cor pulmonale is enlargement of the right ventricle secondary to diseases of the lung, thorax, or pulmonary circulation. Pulmonary hypertension is usually a pre-existing condition in the individual with cor pulmonale. Cor pulmonale may be present with or without cardiac failure. The most common cause of cor pulmonale is COPD. Almost any disorder that effects the respiratory system can cause cor pulmonale.

Clinical manifestations of cor pulmonale include dyspnea, chronic productive cough, wheezing respirations, retrosternal or sub-sternal pain, and fatigue. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. (Polycythemia is often present in cor pulmonale secondary to COPD). Compensatory mechanisms that are secondary to hypoxemia can aggravate the pulmonary hypertension. Episodes of cor pulmonale in a person with underlying chronic respiratory problems are frequently triggered by an acute respiratory tract infection.

The primary management of cor pulmonale is directed at treating the underlying pulmonary problem that precipitated the heart problem. Long term low flow $\mathrm{O}_{2}$ therapy is used to correct the hypoxemia and reduce vasoconstriction in chronic states of respiratory disorders. If fluid, electrolyte, and acid-base imbalances present, they must be corrected. Diuretics and a low sodium diet will help decrease the plasma volume and the load on the heart. Bronchodilator therapy is indicated if the underlying respiratory problem is due to an obstructive disorder. Digoxin use is controversial. However, studies have confirmed a modest effect of digoxin on the failing right ventricle in chronic cor pulmonale. Other treatments include those for pulmonary hypertension, such as vasodilator therapy, calcium channel blockers, and anticoagulants. Theophylline may help due to its weak inotropic effect on the heart. When medical treatment fails, lung transplantation is an option for some patients.

Chronic management of cor pulmonale resulting from COPD is similar to that described for COPD. Continuous low flow $\mathrm{O}_{2}$ during sleep, exercise, and small, frequent meals may allow the patient to feel better and be more active.

Lung transplantation has become an important mode of therapy for patients with a variety of end-stage lung diseases. A variety of pulmonary disorders are potentially treatable with some type of lung transplantation.

Improved patient selection criteria, technical advances, and better methods of immunosuppression have resulted in improved survival rates. Four types of transplant procedures are available: single lung transplantation, bilateral lung transplantation, heartlung transplantation, and transplantation of lobes from a living related donor. Indications for Lung Transplantation

• $\alpha 1$-Antitrypsin deficiency
• Bronchiectasis
• Cystic fibrosis
• Emphysema
• Idiopathic pulmonary fibrosis
• Interstitial lung disease
• Pulmonary fibrosis secondary to other diseases (e.g., sarcoidosis)
• Pulmonary hypertension

Single-lung transplantation involves an incision on the side of the chest. The opposite lung is ventilated while the diseased lung is excised. The lung is removed and the donor lung implanted. Three anastomoses are done: the bronchus, pulmonary artery, and pulmonary veins. In a bilateral lung transplantation, the incision is made across the sternum and the donor lungs are implanted separately. A median sternotomy incision is used for a heart-lung transplant procedure. Chest tubes are placed around the donor lungs to help them re-expand with air. Lobar transplantation from living donors is reserved for candidates who urgently need transplantation and are unlikely to survive until a donor becomes available. The majority of these transplant recipients are patients with cystic fibrosis, and their parents or relatives are donors.

Patients being considered for lung transplantation need to undergo extensive evaluation. The candidate for lung transplantation should not have a malignancy or recent history of malignancy (within the last 2 years), renal or liver insufficiency, or HIV. Typically patients wait an average of 12 to 18 months for a donor lung.

The candidate and the family undergo psychologic screening to determine the ability to cope with a postoperative regimen that requires strict adherence to immunosuppressive therapy, continuous monitoring for early signs of infection, and prompt reporting of manifestations of infection for medical evaluation.

Many transplant centers require preoperative outpatient pulmonary rehabilitation to maximize physical conditioning.

Early postoperative care includes ventilatory support, fluid and hemodynamic management, immunosuppression, detection of early rejection and prevention or treatment of infection. Pulmonary clearance measures, including aerosolized bronchodilators, chest physiotherapy, and deep-breathing and coughing techniques, minimize potential complications. Maintenance of fluid balance is vital in the postoperative phase.

Lung transplant recipients are at high risk for bacterial, viral, fungal, and protozoal infections. Infections are the leading cause of death in the early period after the transplant. Gram-negative bacterial pneumonia is common. Among potential causes of viral infections, cytomegalovirus (CMV) is the most important in lung transplantation patients, usually seen 4 to 8 weeks postoperatively. Clinical manifestations of CMV infection include fever, bone marrow suppression, hepatitis, enteritis, and pneumonitis. Aspergillus is the most common fungal infection.

Immunosuppressive therapy usually includes a three drug regimen of cyclosprine or tacrolimus, azathioprine (Imuran) or mycophenolate mofetil (CellCept), and prednisone. However, because of an array of potential adverse effects and drug interactions, there are limitations to immunosuppressive therapy. Drug levels are monitored on a regular basis. Lung transplant recipients are usually maintained on higher levels of immunosuppressive therapy than other organ recipients.

Acute rejection is fairly common in lung transplantation and can be seen as soon as 5 to 7 days after surgery. It is characterized by low grade fever, fatigue, and oxygen desaturation with exercise. Accurate diagnosis is by transtracheal biopsy. Treatment is high doses of corticosteroids administered IV for 3 days. In patients with persistent or recurrent acute rejection, other strategies may include antilymphocyte antibodies or changing maintenance immunosuppressive drugs.

Bronchiolitis obliterans (an obstructive airway disease causing progressive occlusion) is thought to be a manifestation of chronic rejection in lung transplant patients. The onset is often subacute, with gradual onset of progressive obstructive airflow

defect, including cough, dyspnea and recurrent lower respiratory tract infection. Treatment involves optimum maintenance immunosuppression.

Discharge planning begins in the preoperative phase. Prior to discharge, the patient needs to be able to perform self-care activities, including medication management and activities of daily living, and to accurately identify when to call the transplant team physician. Patients are placed in an outpatient rehabilitation program to improve physical endurance. Home spirometry has been useful in monitoring trends in lung function. Patients are taught to keep medication logs, laboratory results, and spirometry records. The average lung transplant patient takes 13 medications (range, 5 to 24) a day. After discharge, the patients are followed by the transplant team for transplant related issues. The patients return to their primary care team for their health maintenance and routine illnesses. As transplant procedures become more frequent, transplant patients will return to hospitals for other routine procedures. Coordination of care between the transplant team, primary care team, and inpatient teams is essential for ongoing successful management of these patients.

A penetrating injury may cause contusion of the lung or pleura. Pulmonary contusion usually results from sudden compression followed by rapid compression of the thoracic cavity, causing blood to extravasate into pulmonary tissue.

The contusion is usually self-limiting because the pulmonary vasculature is a low pressure system. However, extensive contusion can precipitate pulmonary edema with resultant hypoxemia, hypercapnea, and respiratory acidosis.

Pulmonary contusion may vary from total absence of symptoms to the full spectrum of symptoms associated with non-cardiogenic pulmonary edema. Signs and symptoms (some of which may be delayed) include the following.

• Increasing dyspnea
• Tachypnea
• Increasing restlessness
• Crackles notes on auscultations, and
• Hemoptysis.

Medical treatment of pulmonary contusion depends on the severity of the injury. Treatment may vary from outpatient monitoring to intubation and mechanical ventilating support when pulmonary edema present. The nursing care includes the following:

• Administer analgesic as ordered every 3 hours
• Monitor for fluid overload
• Keep accurate records of all intake and output
• Monitor vital signs every 30 minutes. Report increased pulse and respiration, and
• Monitor breath sound every 30 minutes.
• Monitor ventilating status
• Check for signs of respiratory distress-dyspnea, increased inspiration, changes in breath sound, and
• Check ABG results.
• Monitor for sign of symptom of flail chest
• Support patient to stay in bed until physical status is stabilised
• Stay with patient, listen to patients concernedexplain what is planned, and
• Assist with ADL
• Teach patient/family how to support pulmonary contusion.

Chronic bronchitis is defined by the presence of chronic productive cough for minimum of 3 months per year for at least 2 consecutive years in patients in whom other causes have been excluded, it is characterised by physiologically by hypertrophy and hypersecretion of the bronchial mucous glands and structural alterations of the bronchi and bronchioles.

Chronic bronchitis is caused by the inhalation of physical or chemical irritants or by viral or bacterial infections. The most common inhaled irritant is cigarette smoke (heavy cigarette smoking).

In chronic bronchitis, there is pathologic changes in the lung consisting of:

• Hyperplasia of mucus secreting glands in the trachea and bronchi,
• Increase in globlet cells
• Disappearance of cilia
• Chronic inflammatory charges and narrowing of small airways, and
• Altered functions of alveolar macrophages, leading to increased bronchial infections. Frequently airways are colonised with microorganisms. Infection occurs when the organisms increase. Most common infecting agents are S. pneumoniae and H. influenzae. Excess amounts of mucus are found in the airways and sometimes may occlude small bronchioles and scarring the bronchiole wall may occur chronic inflammation in the primary pathologic mechanism involved in causing the changes characteristics of chronic bronchitis.

The earliest symptom in chronic bronchitis is usually a frequent, productive cough during most winter months. It is often exacerbated by respiratory irritants and cold, damp air. Bronchospasm can occur at the end of paroxysms of coughing. Frequent respiratory infections are other common manifestation. Somewhat later, dyspnea on exertion may develop. Unfortunately a patient often attributes chronic cough to smoking rather than lung disease, thus delaying initiation of treatment. In addition, the patient may not be aware of the cough because he/she becomes accustomed to it.

Hypoxemia and hypercapnea result from hypoventilation caused by increased airway resistance. The bluish red colour of the skin results from polycythemia and cyanosis. Poly-cythemia develops as a result of increased production of red blood cells secondary to the body's attempt to compensate for chronic hypoxemia. Hemoglobin concentration may reach 200 $\mathrm{g} / \mathrm{L}$. Cyanosis develops when there is at least $5 \mathrm{~g} / \mathrm{dl}$ or more of circulating unoxygenated hemoglobin.

The complication of chronic bronchitis are cor pulmonale, acute exacerbation of chronic bronchitis, and acute respiratory failure, peptic ulcer, and GERD, and pneumonia.

Diagnostic studies of COPD include:

• Chest X-ray film, typical finding in chronic bronchitis and increased bronchovascular markings.
• Sputum studies for culture and sensitivity. Neutrophils and bronchial epithelial cells usually occurs in chronic bronchitis.
• ABG
• ECG
• Exercise testing with oximetry (if indicated)
• EEG or cardia nuclear scan (if indicated).

The primary goal of care for COPD patients are to:

• Improve ventilation
• Promote secretion-removal
• Prevent complication and progression of symptoms
• Promote patient comfort and participation in care, and
• Improve quality of life as much as possible.

Medical therapy of chronic bronchitis are depends on symptoms. Pulmonary function tests results in ABG findings. Therapy may include all or some of the modalities outlined here are as follows: i. Supportive measures:

Education of patient and family about the following:

• Avoidance of cigarette smoke
• Avoidance of other inhaled irritants
• Avoidance of persons with upper respiratory infections
• Control of environmental temperature and humidity
• Proper nutrition, and
• Adequate hydration. ii. Specific therapy: Medication such as
• Bronchiodilator-a antitrypsin replacement for those with levels
• Antimicrobials-ampicillium or another broadspectrum antibiotic
• Corticosteroids-to alleviate acute symptoms: e.g., prednisone
• Digitalis-to treat LVF if present. iii. Respiratory therapy in aerosol therapy used to deliver bronchiodilator, through metered cartridge device with spacer at rest.
• Oxygen therapy for patients who are unable to maintain $\mathrm{PaO}_{2}$.

iv. Relaxation exercises

• Meditation for relax v. Breathing retraining vi. Rehabilitation.

Emphysema is defined pathologically by destructive changes in alveolar walls and enlargement of air spaces distal to the terminal non-respiratory bronchioles. It is characterised physiologically by increased lung compliance, decreased diffusing, capacity and increased airway resistance.

The cause of emphysema is not known. However, evidence suggests that proteases released by polymorph nuclear leukocytes or alveolar macrophages are involved in the destruction of the connective tissue of the lungs. Cigarette smoking, infections, ambient air pollution and heredity (AAT-a, antitrypsin) are the other causes of emphysema.

Emphysema is a condition of the lungs characterised by abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of these walls and without obvious fibrosis. Structural changes include:

• Hyperinflation of alveoli
• Destruction of alveolar walls
• Destruction of alveolar capillary walls
• Narrowed tortuous, small airways
• Loss of lung elasticity.

There are two types of emphysema centrilobular and pan-lobular. In centrilobular emphysema the primary area involvement is the central part of the lobula. Respiratory bronchioles enlarge, the walls are destroyed, and the bronchioles become confluent, chronic bronchioles associate with centrilobular types.

Panlobular emphysema, involves distentions and destruction of the whole lobule. Respiratory bronchioles, alveolar ducts and sacs and alveoli are all affected. There is a progressive loss of lung tissue and decreased alveolar-capillary surface area. Severe panlobular emphysema/usually found in persons with alpha-antitrypsin (AAT) deficiency.

An early symptom of emphysema is dyspnea, which becomes progressively more severe. The patient will first complain of dyspnea on exertion that progresses to interfering with ADL to dyspnoea at rest. Minimal coughing is present, with no sputum or smell amounts of mucoid sputum. As more alveoli becomes over distended increasing amount of air are trapped. This causes flattened diaphragm and an increased anteroposterior diameter of the chest, forming the typical barrel chest.

Effective abdominal breathing decreased. The person becomes more of chest breather, relying on the intercostal and accessory muscles. Hypoxemia may be present. The person is characteristically thin and underweight. The person may suffer from proteincaloric malnutrition. Later clubbing finger may develop. The complications as in chronic bronchitis.

Management of emphysema same as in chronic bronchitis. Nursing intervention for persons with chronic bronchitis and pulmonary emphysema are also the same, which include administration of medication such as digitalis and diuretics as prescribed, improving gas exchange, oxygen therapy, improving efficiency for breathing pattern (pursed lip-breathing, forwardleaving position, abdominal breathing and exercise, pulmonary physiotherapy, segmental postural drainage), improving airway clearance, improving nutrition, preventing infection, preventing fluid volume excess, assisting with breathing in rest, assisting with central of environment, and mounting temperature and humidity, etc.

And teach the following: i. Progressive relaxation exercise.

• Contract each muscle to a count of 10 and then relax it.

• Do exercises in quiet room while sitting or lying in a comfortable position.

• Do exercises for relaxing muscle, if desired.

• Have another person serve as a "coach" by giving command to contract specific muscles, count to 10 and relax muscle.

• The following are the examples of exercises helpful to some person with (COPD)

• Raise shoulders, shrug them, and relax for 5 seconds, then relax them completely.

• Make a fist of both hands. Squeeze them lightly for 5 seconds and relax them completely. ii. Meditation exercises:

1. Sit or lie quietly with eyes closed and attempt to relax all muscles beginning with feet and moving upward.
2. Breathe in through the nose slowly (may help to count slowly to 4 on inhalation) and exhale slowly through pursed lips (mentally count to 6) with a natural rhythm, relaxed and peaceful (this can be coached or performed without assistance).
3. Survey the body points of tension, consciously relax the tense areas. The body is peaceful and relaxed.
4. Continue breathing as above. Aware of the feeling of well-being throughout your body. This can be used for 10 to 20 minutes or after 5 minutes go to step 5.
5. Listen for (or visualize) a special relaxation sound (or image). Listen to it closely (or visualise) all the while breathing as above.
6. At this point, positive suggestion can be used, for example, I am in control of my body. When I find myself getting tense, I can take moment to stop and breathe in all the air that I need and let the tension flow away.
7. After mental suggestion, continue breathing easily and slowly come back to normal alert to mental state.
8. Meditation can be used at any time to induce relaxed state of mind (e.g. to promote sleep). While taking care of the person with COPD, nurse has to take the following areas should be addressed in a typical teaching programme for persons with chronic bronchitis or emphysema. i. Patients should be able to explain in lay terms, the basic functions and pathology of their lungs. ii. Avoidance of respirative irritants and maintenance of a proper environment should be emphasised to people with COPD. Inhaled irritants (especially cigarette smoke) pose a serious threat to these persons. Steps the patient can take to reduce or avoid exposure to these irritants.

• Stop smoking. The nurse should be familiar with community programmes and give a list of them to the patient, to involve in it.

• Ask other persons not to smoke in the patient's room. Inhalation of secondary smoke can exacerbate symptoms.

• Pay heed to announcement on radio and TV warning of pollution alert. Do not go outside during an alert.

• Use an air-conditioner or HEPA filter or electrostatic filter to remove particular matter from air.

• Keep filters clean and follow manufacturers' directions for use.

• Use an activated charcoal filter if offending odours or gas pollutants are a problem.

• Avoid abrupt environmental temperature or humidity changes, because they can increase sputum production and cause bronchospasms.

• Use an airconditioner in hot weather

• Use a face mask when going out in cold weather

• Use a dehumidifier or humidifier as appropriate to maintain a humidity of 30 per cent to 50 per cent.

• If air travel is required, check with physician about need for suplemental oxygen.

• Avoid large crowds, especially during known influenza.

• Avoid contact with people who have an upper respiratory infection

• Receive influenza and pneumonia immunisation. iii. The patient should be able to explain the following aspects of the home medication or treatment regimen.

• State name, dose, action and side effects of each infection.

• Explain how and where to use medication ordered on an as needed basis (e.g. bronchodilators, antibiotics, steroids, antacids).

• Describe how to obtain and maintain any needed equipment or supplies (e.g. oxygen, nebulizers, humidifiers, aerosols IPPB machines and syringes medications). iv. The patient should demonstrate how to carry out the specific home exercise programme:

• Specific exercises to be completed

• Frequency of exercise

• Monitor physical response to exercises, such as heart rate increase, increase respiratory rate, or perceived fatigue. v. The patient should be able to list the names and telephone numbers of the appropriate support services.

Asthma is an inflammatory disease characterised by hyper-responsiveness of the airways and periods of bronchospasm, resulting in intermittent airway obstruction. The onset of asthma is sudden, contrary to the slow, insidious progression of symptoms seen in chronic bronchitis and emphysema.

Asthma is caused by increased responsiveness of the trachea and bronchi to various stimuli that cause narrowing of the airways and difficulty in breathing. The common factors triggering an asthma attack include:

• Environmental factors
• change in temperature especially cold air and
• change in humidity; dry air.
• Atmospheric pollutants
• Cigarette and industrial smoke, ozone, sulphur dioxide, formaldehyde.
• Exhaust fumes, oxidants, aerosol sprays.
• Strong odours, perfumes.
• Allergen inhalation.
• Feathers, animal danders, dust mites molds allergens.
• Foods treated with sulfites, beer, wine fruit juices, snack foods salads, potatoes, shellfish, fresh and dried fruits) and metabisulfites, bisulfites, tartrazines.
• Exercise and cold, dry air
• Stress or emotional upset
• Infection: Vital upper respiratory infection, sinusitis
• Medications: Aspirin and NSAIDs, $\beta$-blockers (including eyedrops of glaucoma)
• Enzymes: Including those in laundry detergents
• Occupational exposure: Metal salts, wood and vegetable dust, industrial chemicals and plastics
• Chemicals, toluene and others used in solvents, paints, rubber and plastics
• Hormones, menses
• Gastro-esophageal reflex. (GER)

The mechanism that induces asthma remains unknown. There are two types of asthma. Extrinsic (atopic) and intrinsic (non-atopic).

Extrinsic asthma results from an inflammatory response of the airway caused by mast cell activation, eosinophil infiltration, and epithelial slughing. An attack is triggered by environmental allergen (dust, pollen, molos, animal dander and foods). An initial encounter with an allergen stimulates plasma cells to produce antigen-specific IgE, antibodies that bind mast cells in airways. When exposed to the allergen IgE antigen binding causes mast cell deregulation and release of inflammatory mediators. The result is an intense inflammatory response in the airways.

Intrinsic asthma occurs in adults 35 years of age in older, the asthma attack is often severe. Factors that precipitate attacks include respiratory tract infections, drugs (aspirin, $\beta$-adrenergic antagonism), environmental irritants, (occupational chemicals) air pollutions, cold, dry, air, exercise and emotional stress. Chemical mediator, interacts with the autonomic nervous systems causing inflammation and bronchoconstriction.

An asthmatic attack results from several physiological alterations, include altered immunological response increased airway resistance, increased lung compliance, impaired mucociliary function, and altered carbon dioxide exchange.

The primary pathophysiologic process in asthma is chronic inflammation, which leads to airway hyperresponsiveness (hyperreactivity) and acute airflow limitation. Exposure to allergens or irritants initiates the inflammatory cascade. A variety of inflammatory cells are involved in asthma. Examples of inflammatory cells in asthma are mast cells, macrophages, eosinophils, neutrophils, T and B lymphocytes, and epithelial cells of the airways.

As the inflammatory process begins, mast cells (found beneath the basement membrane of the bronchial wall) degranulate and release multiple

inflammatory mediators. Common inflammatory mediators are leukotrienes, histamine, cytokines (e.g., interleukins 4 and 5), prostaglandin's, and nitric oxide. Some inflammatory mediators have effects on the blood vessels, causing vasodilation and increasing capillary permeability. Some mediators result in the airways being infiltrated by eosinophils, lymphocytes, and neutrophils. The resulting inflammatory process results in vascular congestion; edema formation; production of thick, tenacious mucus; bronchial muscle spasm; thickening of airway walls; and increased bronchial hyperresponsiveness. This whole process is sometimes referred to as the early-phase response in asthma. Clinically it can occur within 30 to 60 minutes after exposure to the allergen or irritant.

Symptoms can recur 4 to 10 hours after the initial attack because of eosinophil and lymphocyte activation and further release of more inflammatory mediators. The epithelial cells also produce cytokines and other inflammatory mediators. This delayed response is called the late-phase response in asthma. Only about 30 to $50 \%$ of patients experience this delayed response. It can be more severe than the earlyphase response and persist for 24 hours or more. It is characterized by a self-sustaining cycle of inflammation. Airflow may be limited from the swelling of the airways with or without bronchoconstriction. Corticosteroids are effective in treating this inflammation.

Untreated inflammation can lead to long-term damage that is irreversible. Chronic inflammation resulting in structural changes in the bronchial wall is known as remodeling. The bronchial smooth muscle hypertrophies and collagen is deposited in the airway walls. The mechanisms responsible for remodeling are thought to be related to chronic or recurrent inflammation of the airways. The combination of damage to the epithelium of the airways, prolonged repair of the epithelium, fibrosis, and increased types of fibroblasts are central to remodeling. The airway smooth muscles hypertrophy and mucus secreting cells undergo hyperplasia in remodeling. There is some evidence that remodeling can occur even in mild asthma of recent onset, but it can be prevented by early introduction of inhaled corticosteroids.

Hyperventilation occurs during an asthma attack as lung receptors respond to increased lung volume from trapped air and airflow limitation. Decreased perfusion and ventilation of the alveoli and increased alveolar gas pressure lead to ventilation perfusion abnormalities in the lungs. The patient will be hypoxemia early on with decreased $\mathrm{PaCO}_{2}$ and increased pH (respiratory alkalosis) as he or she is hyperventilating. As the airflow limitation worsens with air trapping, the patient works much harder to breathe. The $\mathrm{PaCO}_{2}$ will normalize as the patient tires, and then it will rise to produce respiratory acidosis, which is an ominous sign signifying respiratory failure.

Alterations in the neural control of the airways also occur in asthma. The automatic nervous system, consisting of the parasympathetic and sympathetic systems, innervates the bronchi. Airway smooth muscle tone is regulated by the parasympathetic nervous system via the vagus nerve. Afferent and efferent impulses are conducted through the vagus nerve to the medulla and back to the lungs. When airway nerve endings are stimulated by mechanical or chemical stimuli (e.g., air pollution, cold air, dust, allergens), increased release of acetylcholine causes bronchoconstriction.

Asthma is characterised by an unpredictable and variable course. It causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. An attack of asthma may have an abrupt onset or it may be more gradual. Attacks often occur at night may last for a few minutes to several hours. In between, the patient may be asymptomatic with normal and abnormal pulmonary function. However, in some persons, compromised pulmonary functions may result in a state of continuous asthma and chronic debilitation characterised by irreversible airway disease.

The characteristic clinical manifestation of asthma are wheezing cough, dyspnea, and chest tightness after exposed to a precipitating factor or trigger. Expiration may be prolonged.

Instead of normal inspiratory-expiratory ratio of 1:2 it will be prolonged to 1:3 or 1:4. Normally the bronchioles constrict during expiration. However, as a result of bronchospasm, edema and mucus in the bronchioles, the airways become narrower than usual. This takes longer for the air to move out of the

bronchioles. This produce the characteristic wheezing, air trapping and hyperinflation.

The signs and symptoms associated with asthma are correlated with normal lung functions and underlying pathophysiological origins (see aetiology). The character of asthmatic attacks can vary on a continuum from chronic or acute mild intermittent attacks to life threatening status asthmaticus. Severe acute asthma can result in complication such as rib fractures, pneumothorax, pneumomediastinum, atelectasis, pneumonia and status asthmaticus.

Status asthmaticus is a severe, life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure. The causes of which include viral illnesses, ingestion of aspirin or other NSAIDs, emotional stress, increase in environmental pollutants or other allergen exposure, abrupt discontinuation of aerosol medication and ingestion of beta adrenergic blocking agent. In this exhaustion, diminished breath sounds, intubation and mechanical ventilation, complications of status asthmaticus include pneumothorax, pneumomediastenum, acute cor pulmonale with RVF and severe respiratory muscle fatigue leading to respiratory arrest. Death from status asthmaticus is usually the result of respiratory arrest or cardiac failure.

The objective of medical management of asthma are to promote normal functioning of the individual, prevent recurrent symptoms, prevent severe attacks and prevent side effects of medication. The chief aim of various medication is to afford the patient immediate, progressive ongoing bronchial relaxation.

One approach to treat an acute asthmatic attack is as follows: i. Inhalation of beta-agonist such as albuterol sulphate (pro-ventil, ventalin), salmeterol (Serolvent), or metaproterenol sulphate in normal saline. Which stimulates beta 2-receptors in bronchial smooth muscle resulting in smooth muscle relaxation. It starts to act in 10 minutes, effects last 4-6 hours. Here, the nurse has to monitor vital signs, lung sounds, and peak expiratory flow rate (PEFR) before and after treatment. If this is not successful: Go for the following: ii. Methylprednisoline IV loading dose $2 \mathrm{mg} / \mathrm{kg}$ or about 125 mg 6th hrs/then 60-125 mg 6th hourly for 48 hours total or until patient is stable, which reduces inflammation and edema of airway and decreases hyperactivity of airway. The benefits seen within 6 hours full effect in 6-8 hours. When patient is stabilised, change IV to 60 mg oral prednisoline by mouth daily or every other day. The oral prednisoline should be tapered off by 7-10 days, Taper 60 mg over 2 days, 40 mg over 2 days, 30 mg over 2 days and 10 mg over 2 days. iii. Nebulized atrophine sulphate may be tried, or aminophylline may be given IV a pump is used for better control of infusion... which relax bronchial smooth muscle. Loading dose of aminophyllin 4 to $6 \mathrm{mg} / \mathrm{kg}$ over 15 to 30 minutes and then continuous infusion of 0.45 to $0.70 \mathrm{mg} / \mathrm{kg} /$ hour. Patients who have been taking aminophyllin at home will be placed on continuous IV therapy. Rate of infusion is $10-20 \mathrm{mg} / \mathrm{ml}$. Too rapid infusion may cause severe hypotension, premature ventricular contractions, and cardiac arrest.

Here, the nurse has to monitor heart rate and rhythm closely, and report any change immediately to the concerned. Theophylline metabolised by the liver. For persons with liver disease, small doses are used. Patient taking cemitidene, erythromycin or ciprofloxacin require smaller doses. Smokers and those taking phenytoin require larger doses to maintain blood level.

Other common medications for asthma are as follows:

• NSAIDs such as cromolyn, nedocromil, administered through metered dose inhaler (MDI) or nebulizer, decreases airway inflammation and irritation, headache, bad taste in mouth.

• Corticosteroids (dexamethosone, triamcinolene acetonide, Flunisolid, fluticasone) administered through MDI has an anti-inflammatory action. Side effects are sore throat, hoarseness, cough, oral thrush.

• Leukotriene inhibitors/receptor antagonists such as zafir-lukast, zilenton, are anti-inflammatory used orally. Adverse effects include headache, nausea, diarrhoea, dizziness, myalgia, fever, dyspepsia, elevated glanine aminotransferase level.

• Theophylline can be administered orally or parenterally. It is long acting, "bronchiodilator". Side effects are nausea, vomiting, stomach cramps, diarrhea, headache, muscle cramps, tachycardia, irritability, restlessness, serum blood levels should be checked for therapeutic range.

• Anticholinergics (spray) administered through MDI or nebulizer, or nasal spray. It is short-acting bronchiodilator. Side effects are nervousness, dizziness, headache, palpations, blurred vision, nausea, GI distress and dry mouth.

• Beta-2-agonist such as salmeterol administered through MDI. It is long-acting bronchiodilator; may lead to adverse effects-headache, tremor, tachycardia, palpations, naso-pharyngitis, stomachache, cough, rash. When administering the above drugs, nurse has to monitor the responses and side effects of the medication and act accordingly. And when using a metered Dose inhaler (MDI) the nurse has to teach the patient as follows:

• Inhale through nose, then slowly exhale

• Place inhaler 1 to 2 inches off the mouth

• Press down inhaler while simultaneously inhaling one puff deeply. Breath in air from around the mouth piece while inhaling.

• Hold breath for 5 to 10 seconds to allow medication to reach lung.

• Repeat second puff if one is ordered.

• If any untoward effects, stop administering of MDI.

Cystic fibrosis is an autosomal recessive, multisystem disease characterised by altered function of the exocrine glands involving primarily the lungs, pancreas, and sweat glands. Abnormally thick, abundant secretions from mucus glands can lead to a chronic, diffuse, obstructive pulmonary disorder in almost all patients.

Cystic fibrosis is an autosomal recessive disease resulting from mutations in a gene located on chromosome 7. The most common mutations in the CF gene is known as the CF transmembrane regulator (CFTR). The primary defect in the CF is abnormally regulated chloride channel activity. This defect alters ionic transport of sodium and chloride across epithelial surfaces. The high concentration of NaCl in the sweat of the patients with CF results from decreased chloride reabsorption in the sweat duct. The basic pathophysiologic mechanism is obstruction of exocrine gland duct with thick viscous secretions that adhere to the lumen of the ducts. The glands distal to the duct eventually undergo fibrosis.

Cystic fibrosis is an exocrine gland disease involving various systems, i.e., pulmonary, pancreatic/hepatic, GI, reproductive obstruction of the exocrine glands duct or passage ways occurs in nearly all adult patients with CF. Exocrine gland secretions are known to have a decreased water content, altered electrolyte concentration and abnormal organic constituents (especially no mucus glycoproteins), however, the specific biochemical or physiological defect that leads to obstruction is not known.

The following physiological alterations are found in adults with CF include:

• Pulmonary damage
• Gastrointestinal and pancreatic involvement
• Glucose intolerance.

The specific clinical manifestation by symptoms are:

• Pulmonary signs and symptoms of CF includes

• Chronic productive cough and/or recurrent bronchitis or pneumonia

• Crackles and rhonchi decreased pulmonary compliance, digital clubbing, and

• Shortness of breath and dyspnea on exertion, wheezing, and weight loss occurs with respiratory complication and usually indicate need for vigorous therapy.

• Gastrointestinal signs and symptoms include the following:

• Frequent, bulky, greasy stools

• Weight loss

• Cramps and abdominal pain should arouse suspicion of obstruction

• Glucose intolerance signs and symptoms include:

• Polyuria, polydipsia, polyphagia

• Absence of ketoacidosis even with above signs.

Normally mucus production by goblet cells lubricate airways and entraps foreign particles. In CF, excessive amounts of mucus production leads to increased cough and mucus production, inflammation of small airways causing hyperinflation of alveoli give rise to fatigue, shortness of breath, chronic bacterial infections leading to fever, fatigue, shortness of breath, and eroding of a major blood vessel and secondary infection may lead to hemoptysis.

The goals of medical management of CF are to minimize bronchial plugging and to inhibit bacterial colonisation. Measures to minimize bronchial plugging include:

• Chest physiotherapy with chest percussion and postural drainage are performed for 20 minutes two or three times daily and some time much more frequently.
• Administer dornase-alfa 2.5 mg ampule in compressed air-driven nebulizer for reducing visco-elasticity of CF secretion.
• Mucolytic agents may be ordered to thin secretions.
• Humidification of air, according to some physicians
• Antibiotics for infection.

Nursing measures include preventing pulmonary infections, care of hemoptysis, care of pneumothorax and care of cor pul-monale diet, activity and regimen.

• Prevention of pulmonary infection can be made best by:
• Vigorous postural drainage and percussing
• Room humidification if ordered
• Aerosols with a bronchodilator, and
• Monitoring for infection-and take suitable measure accordingly.
• Nursing care and medical care during hemoptysis include:
• Elevate head of bed 45 to 90 degrees
• Turn patient's head to left side to facilitate expectoration of blood
• Provide clean basin frequently so that patient is not made more anxious by amount of blood
• Measure amount of hemoptysis and record time and amounts
• Postural drainage and percussion are contraindicated if haemoptysis present
• Vitamin K as ordered by mouth or subcutaneously to check bleeding
• Stay with the patient until bleeding has subsided and made comfortable to less fearful, and
• Bronchioscopy with endobronchial tamponade may be successful.
• Care of pneumothorax includes proper care for chest tube connected to closed drainage system and other measure used in pneumothorax
• Care of cor pulmonale includes supplement oxygen, long term diuretic therapy. Digoxin if or as ordered by the physician
• Promoting adequate nutrition supplemental fat soluble vitamins and multivitamins and vitamin E. Pancreatin enzyme supplemented
• Patient should be encouraged to be upright position as a tolerated
• Patient and family educated about taking care of CF cases.

Acute respiratory failure (ARF) is used to describe any rapid change in respiration resulting in hypoxemia, hypercapnia, or both. ARF can be classified as hypoxemia or hypercapnia.

Hypoxemic respiratory failure is also related to an oxygenation failure, because the primary problem is inadequate $\mathrm{O}_{2}$ transfer. This can be defined as a $\mathrm{PaO}_{2}$ of 60 mm Hg or less when the patient is receiving an inspired $\mathrm{O}_{2}$ concentration of 60 per cent or greater.

Hypercapnic respiratory failure is also referred to as ventilatory failure because the primary problem is insufficient $\mathrm{CO}_{2}$ removal. It is defined as a $\mathrm{PaCO}_{2}$ above normal ( $>45 \mathrm{~mm} \mathrm{Hg}$ ) in combination with acidemia ( $\mathrm{pH}<7.35$ ).

Many disorders can lead to or associated with respiratory failure which can be divided into pulmonary and nonpulmonary diseases. i. Pulmonary disorders

• Severe infection

• Pulmonary edema

• Pulmonary embolus

• COPD - Chronic obstructive pulmonary disease

• CF - Cystic fibrosis

• ARDS - Acute respiratory distress syndrome

• Cancer

• Chest trauma (flail chest)

• Severe atelectasis

• Airway compromise, secondary to trauma, infection or surgery ii. Non-pulmonary disorders

• CNS disturbance secondary to drug overdose, anaesthesia, head injury

• Neuromuscular disorders i.e., Guillain-Barré syndrome, Myasthenia gravis, multiple sclerosis, poliomyelitis, muscular distrophy, spinal cord injury.

• Postoperative reduction in ventilation following thoracic and abdominal surgery.

• Prolonged mechanical ventilation.

The respiratory system is made up of two basic parts, the gas exchange organ (Lung) and the pump (the respiratory muscles and the respiratory control mechanism). Any alteration in the function of gas exchange unit or pump can result in respiratory insufficiency or respiratory failure. Regardless of the underlying condition, the resultant events or processes that occur in respiratory failure are the same. With inadequate ventilation, the arterial oxygen falls and tissue cells become hypoxic. Carbon dioxide accumulates, leading to a fall in pH and respiratory acidosis.

Lung or gas exchange unit respiratory failure is usually seen in person with underlying primary pulmonary disease such as COPD. In this situation respiratory failure as a result of pathology directly affects the respiratory unit.

Pump failure is associated with extra-pulmonary disorders that may precipitate respiratory failure. In this situation the underlying disorder decreases the ability of lungs to move oxygen and carbon dioxide into and out of the lungs by altering either the central ventilatory control mechanism (e.g. drug overdose) neuromuscular function (e.g. Gullain-Barré syndrome) or chest wall movement (flail chest).

Acute respiratory failure is defined by predetermined physiological criteria, i.e. sudden onset of the following:

• $\mathrm{PaO}_{2} 50 \mathrm{~mm} \mathrm{Hg}$ or less (measured in room air)
• $\mathrm{PaCO}_{2} 50 \mathrm{~mm} \mathrm{Hg}$ or more
• pH 7.35 or less

The sign and symptoms associated with hypercapnia, hypoxemia and respiratory acidosis are:

• Headache
• Irritability
• Increasing somnolence coma
• Asterixis (flapping tremor)
• Cardiac dysrhythmias
• Tachycardia
• Hypotension
• Cyanosis.

The management of respiratory failure includes the following.

1. Medical therapy is based on degree of severity.

• Severe acute respiratory failure, focus on immediate oxygenation and ventilation.
• Less severe acute respiratory failure: underlying cause determined and treated concurrently while treating hypoxemia and hypercapnia.

2. Clinical evaluation a. Diagnosis studies include-ABGs, chest X-ray film, bedside pulmonary spirometry, sputum for culture and sensitivity. b. Treatment includes

• Oxygen therapy.
• Ventilation: may require intubation and mechanical ventilatory supports.
• Treatment of underlying causes.

Nursing care includes improving gas exchange, ventilatory support, mechanical ventilation, improving airway clearance, improving breathing pattern, improving cardiac output, maintaining adequate nutrition, health promotion and prevention.

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, state characterized

by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, systemic consequences also develop.

The term chronic obstructive pulmonary disease encompasses two types of obstructive airway diseases, chronic bronchitis and emphysema. Chronic bronchitis is the presence of chronic productive cough for 3 months in each of 2 consecutive years in a patient in whom other causes of chronic cough have been excluded. Emphysema is an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. Only about $10 \%$ of patients with COPD have pure emphysema. Patients with COPD may have a predominance of one of these conditions, but in reality it is often difficult to determine because the conditions unusually coexist. COPD is discussed in this session as one disease state from the standpoint of pathophysiology and management.

Patients with COPD may have asthma, and some patients with asthma may go on to develop fixed or irreversible airflow obstruction. It may be nearly impossible to differentiate asthma from COPD, especially if the individual has a history of cigarette smoking.

Cigarette smoking: The major risk factor for developing COPD is cigarette smoking. It is still a major public health concern, especially among young people. Nearly all first time use of tobacco occurs before high school graduation, and each day 2000 teens will become regular, daily smokers, with one third of them eventually dying because of a smokingrelated disease. Clinically significant airway obstruction develops in approximately 15 to $20 \%$ of smokers. Cigarette smoking remains the most preventable cause of premature death. In addition to being linked with COPD and lung cancer, cigarette smoking has also been implicated as a factor in cancers of the mouth, pharynx, larynx, esophagus, pancreas, kidney, stomach, colon, cervix, uterus, and bladder. When cigarettes are smoked, tar is inhaled, which contains approximately 4000 chemicals. Over 60 carcinogens have been isolated from cigarette smoke, including cyanide, formaldehyde, and ammonia. Nicotine is probably not a carcinogen, but it has other deleterious effects. It acts by stimulating the sympathetic nervous system, resulting in increased heart rate, increased peripheral vasoconstriction, increased BP, and increased cardiac workload. Nicotine also decreases the amount of functional hemoglobin and increases platelet aggregation. These effects of nicotine compound the problems in a person with coronary artery disease.

Cigarette smoke has several direct effects on the respiratory tract. The irritating effect of the smoke causes hyperplasia of cells, including goblet cells, which subsequently result in increased production of mucus. Hyperplasia reduces airway diameter and increases the difficulty in clearing secretions. Smoking reduces the ciliary activity and may cause actual loss of ciliated cells. Smoking also produces abnormal dilation of the distal air space with destruction of alveolar walls. Many cells develop large, atypical nuclei, which are considered a precancerous condition. After a short time of smoking, changes in small airway function can develop. In the early stages these changes are mostly inflammatory with mucosal edema and an influx of inflammatory cells. In later stages, however, thickening of the airway wall occurs by a remodeling process related to tissue repair and the inability of cilia to clear mucus, thus resulting in accumulation of inflammatory exudates in the airway lumen. Quitting smoking can prevent or delay the development of airflow limitation or reduce its progression.

Carbon monoxide (CO) is a component of tobacco smoke. CO has a high affinity for hemoglobin and combined with it more reality than does $\mathrm{O}_{2}$, thereby reducing the smokers $\mathrm{O}_{2}$-carrying capacity. The smoker inhales a lower percentage of $\mathrm{O}_{2}$ than normal, resulting in less $\mathrm{O}_{2}$ available at the alveolar level. The hearts need for $\mathrm{O}_{2}$ is increased because of the stimulatory effect of nicotine on the sympathetic nervous system. Because the bloods $\mathrm{O}_{2}$-carrying capacity is reduced, the heart must pump more rapidly to adequately supply tissues with $\mathrm{O}_{2} . \mathrm{CO}$ also seems to impair psychomotor performance and judgment.

Passive smoking is the exposure of nonsmokers to cigarette smoke, also known as environmental tobacco smoke (ETS) or secondhand smoke. In adults, involuntary smoke exposure is associated with decreased pulmonary function, increased respiratory symptoms, and severe lower respiratory tract infections such as pneumonia. ETS also is associated with increased respiratory symptoms, and severe lower respiratory tract infections risk for lung cancer and nasal sinus cancer. The cardiovascular system is affected by ETS with increased heart rate and blood pressure and decreased levels of high-density lipoproteins (HDLs).

Occupational Chemicals and Dusts: If a person has intense or prolonged exposure to various dusts, vapors, irritants, or fumes in the workplace, COPD can develop independently of cigarette smoking. If the person smokes, the risk of COPD increases. Exposure to these irritants causes the airways to be hyper responsive.

Air Pollution: High levels of urban air pollution are harmful to persons with existing lung disease. However, the effect of outdoor air pollution as a risk factor for COPD appears to be small compared to the effect of cigarette smoking. Another risk factor for COPD development is fossil fuels that are used for indoor heating and cooking. Many women, particularly because of cooking with these fuels in poorly ventilated areas.

Infection: Infections are a risk factor for developing COPD. Severe recurring respiratory tract infections in childhood have been associated with reduced lung function and increased respiratory symptoms in adulthood. Recurring infections impair normal defense mechanisms, making the bronchioles and alveoli more susceptible to injury. The person with COPD is prone to acute exacerbations of the disease, with $50 \%$ to $75 \%$ of cases thought to be caused by bacteria. These respiratory infections subsequently intensify the pathologic destruction of lung tissue and the progression of COPD. The most common causative organisms are Hemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis.

Heredity: $\alpha 1$-Antitrypsin (AAT) deficiency is the genetic risk factor that leads to COPD. AAT deficiency, an autosomal recessive disorder, accounts for 1 to $2 \%$ of COPD cases. Also known as $\alpha 1$-protease inhibitor, AAT is a serum protein produced by the liver and normally found in the lungs. Severe AAT deficiency leads to premature bullous emphysema in the lungs found via radiologic testing. Normally AAT inhibits the lysis of lung tissues by proteolytic enzymes from neutrophils and macrophages. Emphysema occurs because of the AAT deficiency. Lower levels of AAT result in insufficient inactivation and subsequent destruction of lung tissue. Smoking greatly exacerbates the disease process in these patients.

The level of AAT is controlled by a pair of autosomal co-dominant genes. Low levels of AAT are related to homozygosity for the deficiency gene (ZZ), intermediate levels to heterozygosity (MZ), and normal values to homozygosity for the normal gene (MM). In the recessive gene homozygous group (ZZ), many individuals may have relatively normal lung function, especially those who never smoked. However, those with ZZ have the most severe disease. Clues to AAT deficiencies are the onset of symptoms often occurring by age 40 , minimal to no tobacco use, and family history of emphysema. Chronic lever disease as an infant or adult with increased liver enzyme tests may also be seen. The people with this type of emphysema are primarily of northern European origin. A simple blood test can determine low levels of AAT. Those with borderline or low levels can then be genetically tested. IV administered AAT (Prolastin) augmentation therapy is approved for persons with AAT deficiency. The infusions are administered weekly. Its effectiveness in slowing the progression of the disease continues to be evaluated.

Aging: Some degree of emphysema is common in the lungs of the older person, even a nonsmoker. Aging results in changes in the lung structure, the thoracic cage, and the respiratory muscles. As people age there is gradual loss of the elastic recoil of the lung. The lungs become more rounded and smaller. The number of functional alveoli decreases as a result of the loss of the alveolar supporting structures and loss of the intraalveolar septum. These changes are similar to those seen in the patient with emphysema. Clinically significant emphysema, however, is usually not caused by aging alone. Thinner alveolar walls contribute to loss of alveolar septal tissue and alveolar capillaries.

With fewer capillaries available for gas exchange, arterial $\mathrm{O}_{2}\left(\mathrm{PaO}_{2}\right)$ levels decrease from 80 mm Hg at 20 years of age to 65 to 70 mm Hg by 70 years of age.

Thoracic cage changes result from osteporosis and calcification of the costal cartilages. The thoracic cage becomes stiff and rigid, and the ribs are less mobile. The shape of the rib cage gradually changes because of the increased residual volume (RV), causing it to expand and become rounded. Decreased chest compliance and elastic recoil of the lungs caused by aging affects the mechanical aspects of ventilation and increases the work of breathing. Changes in the elasticity of the lungs reduce the ventilatory reserve, and ability to clear secretions decreases with age.

COPD is characterized by chronic inflammation found in the airways, lung parenchyma (gas exchanging surfaces of the lungs [respiratory bronchioles and alveoli]), and pulmonary vasculature). The pathogenesis of COPD is complex and involves many mechanisms. However, the primary process is inflammation. The inflammatory process starts with inhalation of noxious particles and gases (e.g. cigarette smoke, air pollution). The predominant inflammatory cells, macrophages and lymphocytes (primarily CD8 cells), increase and release inflammatory mediatorsincluding leukotrienes, interleukins and tumor necrosis factor. These mediators cause damage to the lung tissue. Later, neutrophils infiltrate into the lungs and release more inflammatory mediators. The airways become inflamed, resulting in increased numbers of enlarged goblet cells. This results in excess mucus production (or chronic bronchitis). Peripheral airways (small bronchi and bronchioles with internal diameter $<2 \mathrm{~mm}$ ) undergo repeated cycles of injury and repair of the airway walls with resultant structural remodeling. Increased collagen and scar tissue formation in the walls cause fibrosis.

Destruction of the lung parenchyma in COPD patients results in emphysema with significant loss of attachments, which could be likened to rubber bands connecting airways and keeping the airways open. With loss of attachments ("rubber bands"), the peripheral airways collapse. One type of emphysema, called centrilobular, involves dilation and destruction of the respiratory bronchioles and is the most commonly seen in upper lobes in mild disease. The pathologic changes may occur throughout the lungs in severe disease and the pulmonary bed may also be destroyed. The second type of emphysema involves destruction of the alveolar ducts, alveolar sacs, and respiratory bronchioles and is called panlobular. It is most prominent in the lower lobes and is seen with al-Antitrypsin deficiency. Destruction of the lung parenchyma is thought to be due to an imbalance of proteinases/antiproteinases. This occurs as a consequence of inflammation, but there can be a genetic basis to the proteinase imbalance. Individuals have elastin, which provides the structural makeup of the connection tissue of the alveolar wall. In a healthy person, proteinases (elastase is the main component) in the parenchyma function to break down the alveolar walls (elastin). Normally, proteinase inhibitors (called al-antitrypsin [AAT]) prevent this destructive process. In smokers the numbers of neutrophils, macrophages, and other inflammatory cells are increased and with the inflammatory process overwhelm the body's normal AAT defense. Therefore there is destruction of the basic elastin structure of the parenchyma. In addition, inflammatory cells in COPD release a variety of inflammatory mediators such as leukotrienes and interleukins. In the genetic form of emphysema there is a deficiency of AAT, and an imbalance of proteinases/antiproteinases occurs. As the disease progresses, these microscopic lesions may progress to bullae in the lung parenchyma or blebs in the visceral pleura. These anatomic changes can be likened to a balloon that has been blown up too many times. Bullae and blebs are areas with greatly reduced diffusion of gases as the alveolar capillary bed is destroyed.

In COPD, as the supporting structures of the lung are destroyed, there is no pull or traction on the walls of the bronchioles. Like air being blown into a paper bag, air goes into the lungs easily but is unable to come out on its own; it remains in the lung. Thus the bronchioles tend to collapse (especially on expiration) and air is trapped in the distal alveoli. This trapped air in the lungs gives the patient the typical barrel-chested appearance. In COPD the lungs can be inflated easily but can only partially deflate.

Pulmonary vascular changes can begin early in the disease. Inflammatory cells infiltrate the smooth

muscle of the blood vessels causing thickening as the disease advances. Because of the loss of alveolar walls and the capillaries surrounding them, the amount of surface area that is available for diffusion of $\mathrm{O}_{2}$ decreases. The patient with COPD compensates for this problem by increasing the respiratory rate to increase alveolar ventilation. Typically, the patient does not have difficulty with hypoxemia at rest until late in the disease. However, hypoxemia may develop during exercise, and the patient may benefit from supplemental $\mathrm{O}_{2}$. Air can move into the lungs, thus there is ventilation. However, because of the anatomic changes noted previously, perfusion of gases is affected, and thus there is a ventilation/perfusion imbalance. Hypercapnia and respiratory acidosis do not develop until late in the disease process. In severe cases, collagen deposition in the vessels along with emphysematous destruction of the capillary bed occurs, leading to pulmonary hypertension and cor pumonale; the prognosis is poor.

These changes in the lungs result in the following characteristic disease manifestations: mucus hypersecretion, dysfunction of the cilia, airflow limitation and hyperinflation of the lungs, gas exchange abnormalities, pulmonary hypertension, and cor pulmonale (see Fig. 9.13). Mucus hypersecretion and dysfunction of cilia lead to chronic cough and sputum production. Inability to expire air (largely irreversible) is the main smaller airways and is due to remodeling. Because of the loss of alveolar walls and attachments, the elastic recoil of the lung is decreased. Recoil is also affected by the influx of inflammatory cells and exudates in the bronchi together with hyperinflation of the lungs.

COPD has been shown to have systemic effects with inflammation (oxidative stress and inflammatory cells) and skeletal muscle wasting. Cigarette smoking begins the process of inflammation via oxidative stress, but inflammation appears to be sustained years after smoking ceases. This mechanism is being investigated. These effects limit the exercise abilities of the patient and worsen the prognosis.

Clinically it is common to find a combination of emphysema and chronic bronchitis in the same person, often with one condition predominating. Patients with COPD may also have asthma, and if they experience poorly reversible airflow limitation, the symptoms may be indistinguishable from COPD, but clinically are treated as asthma. Pathologically, the types of inflammatory cells are quite different between COPD and asthma.

Clinical manifestations of COPD typically develop slowly around 50 years of age after 20 pack years of cigarette smoking. A diagnosis of COPD should be considered in any patient who has symptoms of cough, sputum production, or dyspnea, and/or a history of exposure to risk factors for the disease. An intermittent cough, which is the earliest symptom, usually occurs in the morning with the expectation of small amounts of sticky mucus resulting from bouts of coughing. Patients usually seek medical help when they have an acute respiratory infection, with dyspnea being the main concern.

Dyspnea is often progressive, and usually occurs with exertion. However, patients may dismiss the importance of this symptom as they rationalize, "I'm just getting older". They change behaviors to avoid dyspnea, such as taking the elevator. Gradually the dyspnea interferes with daily activities, such as carrying grocery bags, and they cannot walk as fast as their spouse or peers.

In late stages of COPD, dyspnea may be present at rest. As more alveoli become over distended, increasing amounts of air are trapped. This causes a flattened diaphragm and an increased anterior-posterior diameter of the chest, forming the typical barrel chest. Effective abdominal breathing is decreased because of the flattened diaphragm from the over distended lungs. The person becomes more of a chest breather, relying on the intercostal and accessory muscles. However, chest breathing is not efficient breathing.

The language that patients use to describe the dyspnea may be a key to determining that the etiology is respiratory rather than other causes such as heart failure. Patients with dyspnea because of COPD (compared to heart failure) often say, "My breath does not go out all the way". They may also use words such as "heaviness", "gasping", and "increased effort to breathe" to describe the dyspnea.

The cough initially may be intermittent. Later it is present every day, but is seldom present during the

night. There are ranges in the amount of sputum produced. It is difficult to quantify the amount of sputum produced because many people swallow it, particularly women. In some people the cough may be nonproductive.

Wheezing and chest tightness may be present, but may vary by time of the day or from day to day, especially in patients with more severe disease. The wheeze may arise from the laryngeal area, or wheezes may not be present on auscultation. Chest tightness, which often follows activity, may feel similar to muscular contraction.

During physical examination a prolonged expiratory phase of respiration, wheezes, or decreased breath sounds are noted in all lung fields. The patient may need to breathe louder than normal for auscultated breath sounds to be heard. The anteriorposterior diameter of the chest is increased ("barrel chest") from the chronic air trapping. The patient may sit upright with arms supported on a fixed surface such as an overbed table (tripod position). The patient may naturally purse lips on expiration (pursed-lip breathing) inspiration. Edema in the ankles may be the only clue to right-sided heart involvement.

Over time, hypoxemia ( $\mathrm{Pa} \mathrm{O}_{2}<60 \mathrm{~mm} \mathrm{Hg}$ or $\mathrm{O}_{2}$ saturation $<88 \%$ ) may develop with hypercapnia ( $\mathrm{Pa} \mathrm{O}_{2}>45 \mathrm{~mm} \mathrm{Hg}$ ) later in the disease. The bluish-red color of the skin results from polycythemia and cyanosis. Polycythemia develops as a result of increased production of red blood cells as the body attempts to compensate for chronic hypoxemia. Hemoglobin concentrations may reach $20 \mathrm{~g} / \mathrm{dl}(200 \mathrm{~g} / \mathrm{L})$ or more. Cyanosis develops when there is at least $5 \mathrm{~g} / \mathrm{dL}$ ( 50 $\mathrm{g} / \mathrm{L}$ ) or more of circulating unoxygenated hemoglobin.

As noted previously, it is sometimes quite difficult for the health care provider to distinguish COPD from asthma. However, there are some clinical features that are different.

Classification of COPD: COPD should be considered in any person with an exposure to risk factors such as cigarettes and/or environmental or occupational pollutants and/or chronic cough and dyspnea. The diagnosis is confirmed by spirometry. COPD can be classified as at risk, mild, moderate, severe, and very severe. The FEV1/FEV $<70 \%$ establishes the diagnosis of COPD, and severity of obstruction (as indicated by FEV1) determines the stage of COPD. The management of COPD is primarily based on the patient's symptoms, but the staging provides a general guideline for the type of interventions.

Cor pulmonale: Cor pulmonale is hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension. It is caused by diseases affecting the lungs or pulmonary blood vessels. Cor pulmonale is a late manifestation of chronic pulmonary heart disease. The patient benefits most when a diagnosis of pulmonary heart disease can be made early so therapy can be instituted. In patients with severe COPD, $40 \%$ demonstrate cor pulmonale, and the prognosis is poor. In COPD there may be an anatomic reduction of the pulmonary vascular bed as seen in emphysema with bullae. These patients would have increased pulmonary resistance.

Normally the right ventricle and pulmonary circulatory system are low pressure systems compared with the left ventricle and systemic circulation. When pulmonary hypertension develops, the pressures on the right side of the heart must increase to push blood into the lungs. Eventually, right-sided heart failure develops.

The clinical manifestations of chronic pulmonary heart disease and cor pulmonale are related to dilation and failure of the right ventricle with subsequent intravascular volume expansion and systemic venous congestion. Dyspnea is a usual symptom, and is associated with hypoxemia and hypercarbia. Lung sounds are normal or crackles may be heard in the bases of the lungs bilaterally. Heart sound changes include accentuation of the pulmonic component of the second heart sound, right-sided ventricular diastolic S3 gallop, and a loud pulmonic component of S2 along the left sternal border. ECG changes include increased P wave amplitude (P pulmonale), a tendency for right axis deviation, and incomplete right bundle branch block. Overt manifestations of right-sided heart failure may develop, which include distended neck veins (jugular venous distention), hepatomegaly with right upper quadrant tenderness, ascites, epigastric distress, peripheral edema, and weight gain.

Management of cor pulmonale includes continuous low-flow $\mathrm{O}_{2}$. Long-term $\mathrm{O}_{2}$ therapy improves survival of hypoxemic patients, especially when used $>15$ hours per day. Vasodilator therapy has not demonstrated sustained benefit and is not recommended on a routine basis. Although the use of digitalis is not indicated for right-sided heart failure, it may be used, but serum creatinine and blood urea nitrogen (BUN) are needed to monitor renal function as diuretics can cause volume depletion. Electrolytes must be monitored to assess for hypokalemia, which can predispose to dysrhythmias.

Exacerbations of COPD: Exacerbations of COPD are signaled by a change in the patients usual dyspnea, cough, and/or sputum that is different from the usual daily patterns. These flares require changes in management. Patients have an increase in dyspnea, sputum volume, and/or sputum purulence. They may also have nonspecific complaints of malaise, insomnia, fatigue, depression, confusion, decrease in exercise tolerance, increased wheezing, increased cough, or fever without other causes.

As the severity of COPD increases, exacerbations of COPD are associated with poorer outcomes. Exacerbations of COPD may be treated at home or in the hospital intermediate care unit or intensive care unit, depending on the severity. The primary causes of exacerbations of COPD are tracheobronchial infection and air pollution. Bacteria account for 33 to $75 \%$ of the cases of infection. The most common organisms causing exacerbations are $H$. influenza, $M$. catarrhalils, and S. pneumoniae. Other causes of COPD exacerbations include viruses.

Medications used to decrease airway resistance during exacerbations of COPD are bronchodilators and oral systemic corticosteroids. If a patient has clinical signs of airway infection (e.g. increased volume and change in color of sputum and/or fever, especially in the severe stages of COPD with more than three to four exacerbations per year), antibiotic treatment is usually used. Therapies used to treat exacerbations of COPD in the hospital are similar to home management, except supplemental oxygen therapy titrated by ABG measurement may be used. Attempts are made to use noninvasive mechanical methods (e.g., intubation). Teaching the patient and family early recognition of signs and symptoms of exacerbations is important to promote early treatment to prevent hospitalization and possible respiratory failure.

Acute Respiratory Failure: Patients with severe COPD who have exacerbations are at risk for the development of respiratory failure. Frequently, COPD patients wait too long to contact their health care provider when they develop fever, increased cough and dyspnea, or other symptoms suggestive of exacerbation of cor pulmonale may also lead to acute respiratory failure. Discontinuing bronchondilator or cortisoteroid medication may also precipitate respiratory failure. The use of $\beta$-adrenergic blockers (e.g., propranolol [Inderal]) may also exacerbate acute respiratory failure in the patient with a reversible component to the COPD. However, cardio selective $\beta$ adrenergic blockers (e.g. atenolol, metoprolol) should not be withheld from patients with mild to moderate diseases because they do not produce clinically significant problems with respiration.

The indiscriminate use of sedatives, benzodiazepines, and opioids, especially in the preoperative or postoperative patient who retains $\mathrm{CO}_{2}$, may suppress the ventilatory drive and lead to respiratory failure. The person with COPD who retains $\mathrm{CO}_{2}$ should be treated with low flow rates of $\mathrm{O}_{2}$ with careful monitoring of ABGs to avoid hypercarbia to ensure that adequate oxygenation occurs, and to monitor for acidosis. It has been thought that high flow rates of $\mathrm{O}_{2}$ depress the respiratory center and that the patients respirations will diminish or cease. However, it is vital to provide adequate oxygen while assessing the ABGs , rather than not providing $\mathrm{O}_{2}$ because of the fear of $\mathrm{CO}_{2}$ narcosis.

Surgery or severe, painful illness involving the chest or abdominal organs, may lead to splinting and ineffective ventilation and respiratory failure. To prevent postoperative pulmonary complications, careful preoperative screening, which includes pulmonary function tests and ABG assessment, is important in the patient with a heavy smoking history and/or COPD.

Peptic Ulcer and Gastroesophageal Reflux Disease: The incidence of peptic ulcer disease is increased in persons with COPD. The person for this occurrence is

partly explained by hypersecretion of gastric acid resulting from increased arterial $\mathrm{CO}_{2}$ and decreased arterial $\mathrm{O}_{2}$ tension. This occurs only in patients who chronically retain $\mathrm{CO}_{2}$. The ulcers are more commonly in the duodenum rather than stomach and do not cause pain. It is important to test gastric aspirates and feces for occult blood.

Gastroesophageal reflux disease (GERD), which may or may not be associated with a hiatal hernia, occurs frequently in patients with COPD and may aggravate respiratory symptoms. The reflux and accompanying heartburn may be aggravated or even precipitated by theophylline or $\beta 2$-adrenergic agonists. However, patients with severe COPD and GERD have also been found to have asymptomatic GERD.

Depression/Anxiety: Patients with COPD experience, many losses as the disease progresses over time. They can feel helpless with low self-esteem and unable to vent their emotions for fear of compromising their breathing. The reported prevalence of depression in COPD varies, but may be four times more frequent in COPD than in the general population. Anxiety can complicate respiratory compromise and may precipitate dyspnea and hyperventilation. When a person is exceptionally dyspnic, particularly if it occurs suddenly, the person becomes anxious and tries to breathe faster, thus affecting his or her oxygenation status. Proper screening for anxiety and depression by health care providers is needed for a proper diagnosis.

After diagnosis, treatment consists of cognitive and behavioral psychotherapy and/or pharmacotherapy. Selective serotonin reuptake inhibitors (SSRIs) are often used for both depression and anxiety. Buspirone, which is one medication used to treat anxiety, has few if any respiratory depression effects. Benzodiazepines are avoided because they may depress the respiratory drive and may be habit forming. The nurse should explore the psychologic realm of the patient's disease and the impact it has on the patient's quality of life. Providing sufficient time for nursing interventions during an acute exacerbation is important to help reduce anxiety. When the patient becomes anxious because of dyspnea, the use of pursed-lip breathing and short-acting bronchodilators may be appropriate.

The diagnosis of COPD is confirmed by pulmonary function tests. Goals of the diagnostic workup are to confirm the diagnosis of COPD via spirometry, evaluate the severity of the disease, and determine the impact of the disease on the patient's quality of life. These factors enable the health care provider to design an individualized treatment plan. In addition to pulmonary function tests, other diagnostic studies are performed. Chest X-rays taken early in the disease are seldom diagnostic unless bullous disease is present. Patient may have significant airflow limitation as demonstrated by spirometry but not chronic cough. Most patients seek medical help because of dyspnea that starts affecting their daily activities. Later in the disease the findings presented in may be present.

A history and physical examination are extremely important in a diagnostic workup. Pulmonary function studies are useful in diagnosing and assessing the severity of COPD. Usually spirometry is ordered before and after bronchodilation. The most significant findings are related to increased resistance to expiratory airflow. Typical findings include the following:

• Reduced FEV1, FEF25%-75% FEV1/FVC ratio, diffusing capacity for carbon monoxide
• Increased residual volume, functional residual capacity (FRC) When the FEV1/FVC ratio is less than $70 \%$, it suggests the presence of obstructive lung disease. The value of FEV1 in milliliters can provide a guideline to determine the severity of the patients lung disease and the degree of disease progression.

The body mass index (BMI) and degree of dyspnea are useful in predicting outcomes, such as survival. Current practice guidelines recommend that the BMI and dyspnea be evaluated in all patients. BMI is obtained by dividing weight (in kilograms [kg]) by height (in square meter [m2]). A BMI below $21 \mathrm{~kg} / \mathrm{m}^{2}$ is associated with an increase in mortality rate. Functional dyspnea can be assessed with the Medical Research Council Dyspnea Scale from level 0 (no trouble with breathlessness except with strenuous exercise) to level 4 (too breathless to leave the house or breathless when dressing or undressing).

ABGs are usually assessed in the sever stages and monitored in patients hospitalized with acute

exacerbations. In the later stages of COPD, typical findings are low $\mathrm{PaO}_{2}$, elevated $\mathrm{PaO}_{2}$, decreased or lownormal pH , and increased bicarbonate $(\mathrm{HCO} 3)$ levels. In the early stages there may be normal or only slightly decreased $\mathrm{PaO}_{2}$ and a normal $\mathrm{PaO}_{2}$. A6-minute walk to determine $\mathrm{O}_{2}$ desaturation that occurs with exercise. AnECG may be normal or show signs indicative of right ventricular failure (e.g., low voltage, right-axis deviation, cor pulmonale). An echocardiogram or gated pool nuclear blood study can be used to evaluate right-sided ventricular and left ventricular function. Sputum for culture and sensitivity may be obtained, if the patient is hospitalized for an acute exacerbation and has not responded to empiric therapy with antibiotics.

The primary goals of care for the COPD patient are to (1) prevent disease progression, (2) reliever symptoms and improve exercise tolerance, (3) prevent and treat complications, (4) promote patient participation in care, (5) prevent and treat exacerbations, and (6) improve quality of life and reduce mortality risk (see Evidence-Based Practice box). The majority of patients are treated as outpatients. They are hospitalized for exacerbations of COPD and potential complications when respiratory failure, pneumonia, and failure and/or cor pulmonale are also present. Environmental or occupational irritants should be evaluated for their possible negative effect, and ways to control or avoid them should be determined. For example, aerosol hair sprays and smoke-filled rooms should be avoided. The patient with COPD is extremely susceptible to pulmonary infections. The patient with COPD should have a vaccination with influenza virus vaccine yearly and with pneumococcal vaccine. Pneumucoccal revaccination is recommended once if the patient is $\geq 65$ years of age, the vaccination was $\geq 5$ years previously, and the patient was $<65$ years of age at the time of the primary vaccination.

Exacerbations of COPD should be treated as soon as possible especially if the patient is in the severe stages of COPD. Often the best indication of the presence of a bacterial infection is the increasing quantity, viscosity, or purulence of sputum. Some patients are given a prescription for 7 days to 10 days supply of antibiotics and are instructed to begin taking them at the first signs of change in sputum. The most common antibiotics given for outpatients are macrolides (e.g., azithromycin [Zithromax]), doxycycline and newer cephalosporins (e.g., cefpodoxime [Vatnin]). Amoxicillin may be used, but patterns of antibiotic resistance are limiting its use. If the patient has failed prior antibiotic therapy or is hospitalized, common antibiotics are amoxicillin/clavulanate (Agumentin), or respiratory fluoroquinolones (e.g. levofloxacin [Levaquin]).

Cessation of cigarette smoking in all stages of COPD is the single most effective and cost-effective intervention to reduce the risk of developing COPD and stop the progression of the disease. After discontinuation of smoking, the accelerated decline in pulmonary function slows and pulmonary function usually improves. Normally individuals after age 35 lose approximately 20 to 25 ml (as measured by FEV1) of lung function per year as measured by spirometry. Persons with COPD who continue to smoke lose approximately 50 ml per year. With the cessation of smoking, the loss can fall to almost nonsmoking levels at 35 ml per year. Thus the sooner the smoker stops, the less pulmonary function is lost and the sooner the symptoms decrease, especially cough and sputum production (see Evidence-Based Practice box).

Medications for COPD can reduce or abolish symptoms, increase the capacity to exercise, improve overall health, and reduce the number and severity of exacerbations. Presently no drug modifies the decline of lung function with COPD. Bronchodilator drug therapy relaxes smooth muscles in the airway and improves the ventilation of the lungs, thus reducing the degree of breathlessness. Although patients with COPD do not respond as dramatically as those with asthma to bronchodilator therapy, a reduction in dyspnea and an increase in FEV1 are usually achieved. The inhaled route of medication is preferred and given

on a pm or regular basis. Medications are given in a stepwise fashion.

Bronchodilator medications commonly used are $\beta 2$adrenergic agonists, anticholinergic agents, and methylxanthines. The choice of bronchodilator depends on the availability and the patient's response. However, when the patient has mild COPD or intermittent symptoms, a short-acting bronchodilator is used as needed. Short-acting bronchodilators increase exercise tolerance. Albuterol or ipratropium (Atrovent) may be used as single agents, but combining bronchodilators improves their effect and decreases the risk of adverse effects, compared with the use of a single agent. As a single agent, ipratropium (Atrovent) is superior to albuterol because the only side effect is usually dry mouth.

These two agents can be nebulized together (DuoNeb) or delivered by one MDI (Combivent).

As symptoms persist or moderate stages of COPD develop, a long-acting bronchodilator is used in addition to a short-acting bronchodilator. Salmeterol (Serevent) is a widely used long-acting $\beta$-2-adrenergic agonist, and unlike in drug therapy for asthma, it can be used in COPD as monotherapy. Formoterol (Foradil) is another long-acting $\beta 2$-agonist.

Titropium (Spiriva), a long-acting anticholinergic, can be used for daily therapy of bronchosapsm, and dyspnea in COPD. Tiotropium also improves bronchodilation, results in less dyspnea, improves quality of life, and deceases the number of COPD exacerbations when compared with ipratropium (Atrovent). Tiotropium is the first inhaled drug for COPD to be dosed once a day.

The use of long-acting theophyline in the treatment of COPD is controversial because it interacts with many drugs. Although it has some action as a mild bronchodilator in the patient with partial reversibility of airflow obstruction, its main value may be to improve contractility of the diaphragm and decrease diaphragramatic fatigue.

Inhaled corticosteroid therapy may be beneficial for patients with moderate-to-severe COPD. However, inhaled corticosteroids (ICS) do not appear to help patients with mild COPD. ICS combined with longacting $\beta 2$-adrenergic agonists (e.g., fluticasone/ salmeterol [Advair]) are more effective than the single drug therapy. Oral corticosteroids should not be used for long-term therapy in COPD.

$\mathrm{O}_{2}$ therapy is frequently used in the treatment of COPD and other problems associated with hypoxemia. Longterm $\mathrm{O}_{2}$ therapy (LTOT) improves survival, exercise capacity, cognitive performance, and sleep in hypoxemic patients. $\mathrm{O}_{2}$ is a colorless, odorless, tasteless gas that constitutes $20.95 \%$ of the atmosphere. Administering supplemental $\mathrm{O}_{2}$ raises the partial pressure of $\mathrm{O}_{2}\left(\mathrm{PO}_{2}\right)$ in inspired air. Used clinically it is considered a drug. For reimbursement purposes, it is considered durable medical equipment, which Medicare covers when certain clinical criteria are met (i.e., the patients $\mathrm{O}_{2}$ saturation needs to be $\leq 88 \%, \mathrm{PaO}_{2} \geq 55 \mathrm{~mm} \mathrm{Hg}$ ). Indications for Use: Goals for $\mathrm{O}_{2}$ therapy are to reduce the work of breathing, maintain the $\mathrm{PaO}_{2}$, and/or reduce the workload on the heart, keeping the $\mathrm{SaO}_{2}>90 \%$ during rest, sleep and exertion, or $\mathrm{PaO}_{2}>60$ $\mathrm{mm} \mathrm{Hg} . \mathrm{O}_{2}$ is usually administered to treat hypoxemia caused by (1) respiratory disorders such as COPD, pulmonary hypertension, cor pulmonale, pneumonia, atelectasis, lung cancer, and pulmonary emboli; (2) cardiovascular disorders such as myocardial infarction, dysrhythmias, angina pectoris, and cardiogenic shock; and (3) central nervous system disorders such as overdose of opioids, head injury, and disordered sleep (sleep apnea). Methods of administration: The goal of $\mathrm{O}_{2}$ administration is to supply the patient with adequate $\mathrm{O}_{2}$ to maximize the $\mathrm{O}_{2}$-carrying ability of the blood. There are various methods of $\mathrm{O}_{2}$ administration. The method selected depends on factors such as the fraction of inspired $\mathrm{O}_{2}\left(\mathrm{FIO}_{2}\right)$ required by the patient and delivered by the device, the mobility of the patient, humidification required, patient cooperation, comfort, cost, and available financial resources. $\mathrm{O}_{2}$ delivery systems are classified as low- or highflow systems. Most methods of $\mathrm{O}_{2}$ administration are low-flow devices that deliver $\mathrm{O}_{2}$ in concentrations that vary with the person's respiratory pattern. In contrast, the Venturi mask is a high-flow device that delivers fixed concentrations of $\mathrm{O}_{2}$ independent of the patient's respiratory pattern. With the Venturi mask, $\mathrm{O}_{2}$ is delivered to a small jet (Venturi device) in the center of a wide-based cone. Air is entrained (pulled through)

openings in the cone as $\mathrm{O}_{2}$ flows through the small jet. The mask has large vents through which exhaled air can escape. The degree of restriction or narrowness of the jet determines the amount of entrainment and dilution of pure $\mathrm{O}_{2}$ with room air, and thus the concentration of $\mathrm{O}_{2}$ delivered can be precise. Mechanical ventilators are another example of a high-flow $\mathrm{O}_{2}$ delivery system. Because room air is mixed with $\mathrm{O}_{2}$, in low-flow systems, the percentage of $\mathrm{O}_{2}$ delivered to the patient is not as precise as with high-flow systems.

Humidification and nebulizers: $\mathrm{O}_{2}$ obtained from cylinders or wall systems is dry. Dry $\mathrm{O}_{2}$ has an irritating effect on mucous membranes and dries secretions. Therefore it is important that $\mathrm{O}_{2}$ be humidified when administered, wither by humidification or nebulization. A common device used for humidification when the patient has a catheter, cannula, or low-flow mask is a bubble through humidifier. It is a small jar filled with sterile distilled water that is attached to $\mathrm{O}_{2}$ source by means of a flow meter. $\mathrm{O}_{2}$ passes into the jar, bubbles through the water, and then goes through tubing to the patient's catheter, cannula, or mask. The purpose of the bubble-through humidifier is to restore the humidity conditions of room air. However, the need for bubblethrough humidifiers at flow rates between 1 and 4L per minute is dependent on patient preference.